NCC232350_FRO Submitted_20230804

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
77�xNo person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by Wake County Department of
h'f7nlll 4.4u�er Y Environmental Serviyes, Water Quality Division. (Please type or print and, d the question is not
applicable, place NIA in the blank,)
Part A.
1- Project Name V �LQ D V, LLB j L 1p If A S -
2. Location cf land-disturbing activity, Jurisdiction (Wake Co or Municipality)
HighwaylStreet t,4VLt Latitude 5 '1 064�u Longitude
A W. .-6k L 1113
3 Approximate date land-distufing activity will commence
4. Type of development(residential, commercial. industrrat, institutional, atc-)
5- Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas)
6- Person to contact shuuld erosion and sediment control issues arise during land-disturbing activity: 3
Name J` t ' E-mail Address --i t' • c-4 �'_ -t G ur����5. L4•
Te!ephone 919 WA Call# q 19 Wo Fax#
7 Landowner(s) of Record(attach accompanied page to list additional owne,,5)-
Nanie(s) ` TeWpttone Fax or E-mall address �_4
L1}L-1kJLiJ ItJ!U_ uiJ A, %'il LA
Current Mailing Address Current Street Address
,f r� ►3 ,� ,.l�. ��St
City State Zip City State Zap
8 !]ec-d 8flok Na.
4�a r� Page NO- Diy 5s Prov de a copy of the most current dead.
Part B.
t. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide
comprehensive list of all respro lnsVe parties on an attached sheet_ Include requested informaf}ian).. ,n
1� 1 �.�L a-a ` + 1.L L. .S P �{• �'s i l_,!1�t AA
Name P E-mail Andres$ 1.1
Current Mailing Address Current Strut Address
City Swe Zip City Stlatte� Zip
Telephone y Fax Number 1!•t'

I (a) If the Financially Responsible Patty is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, pnXess, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Dtsturbanre Permit-
Name E-mail Address
r``
L '—
Current Mailing Address i + Zu►rent Street Address
LJ I
City State It City State Zip
Telephone Fax Number
(b) if the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name. attach a copy of the Certiftcate of Assumed Name. If the Financially Responsible
Party/is a Corporation. give name and street address of the Registered Agent.
Name of Registered Agent E-mail Andres
Current Mailing Addfess Current Street Address l
City 'i r State Zip City '' State Zip
Telephone �1 �o rt �q ( Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This farm must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact. or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person) I agree to provide
corrected information should there be any change in the information provided herein.
Type or t name' Title ar Authority
bI� AWn--ji
Signature'4 Date
( .L 6_ a Notary Public of the County of
State of North Carolina. hereby certify that S��� �. }}c�.� ��. appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by hire.
Witness my hared and notarial seal, lhts i day of ►-1.ti ,u,,t 20-�
FSaFaofi►tr,rrr> C'1Sst40TA�r PUB iC Notary
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n mLssionrm �� M commission expires Esc re5lgilugYY 22.21126 y
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