NCC232665_FRO Submitted_20230905

WAKE COUNTY FINANCIAL RESPONSIBILITY:OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKFNo person may initiate any rand-disturbing actrvrty on one or more acres as covered by the Wake
County Urufred DevelopmentOrdinance d cle
COUNTY se
danentatron control plan haveOr been before completed andthis approvedform an by Wake Couceptabntyr Departmenterosionand of
Environmental Services. Water Duality Division (Please type or print and. if the question is not
applicable.place NiA in the blank.)
Part A.
I protect Name Lot 23 Southern Hills
2 Location of land-disturbing activity Jurisdiction Wake (Wake Co_or Municipality)
Hiphwaytstreel Sky Vista Way Latitude 35.958370 Longitude -78.688698
3. Appproxm ate dale land-disturbing activity will commence 9/15/2023
4. Type of development(residential commercial,industrial, institutional,etc_). residential
5 Total acreage disturbed or uncovered (including off-site utilities and borrow waste
areas) 0.7
6 Person to contact should erosion and sediment control issues arise during land-disturbing activity•
Name Samuel St.Clair II E..rtaii [e-mail]
Telephone [phone] _Cell# Fax tt
7 Landowner(s)of Record(attach accompanied page to list additional owners):
Samuel St.Clair II 919-559-2071
Name(s) Telephone Fax or E-mail address
1619 Oberlin Road 1619 Oberlin Road
Gixnent Mailing A4drais Current street Adam
Raleigh, NC 27608 Raleigh,NC 27608
City State Zip City State Zip
8 Deed Book No 019171 page No. 01703 Provide a copy of the most current deed
Part B.
1. Person(s) or firm(s) who are fnanaally responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet Include requested information):
St.Clair construction group LLC [e-mail]
Name - - - - E-mari Address
1619 Oberlin road 1619 Oberlin road
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number

•
2 ta)it se Fr,ncoSy Raeporelb Party a not a reemne of Wars Covey.*My y•Oat*til Gael b
Wall*Canty b recent.any mate.Pisa ataadale al any action co leggy prmaserr0 ruing ors of any
/neon ',Wale to tte Wars Carey Erosion one saenrnrsewn Conger Ordnance rro+ar faro
Oeaabr,ce Permit
Nana E4naa Address
Curiae teaming Address Current Seurat Address
Cry Stale zip Csy Sole zq
TaYplwre Fax Number
(b)M She fnrmtdy Respoeb).Prty N a Partnership or other parson snow:ono n business under an
asatnsd name.Media copy of the Certificate of Assumed Name If the fsoma/y Responsible •
Party to a Corporation.pee name and greet address of the Regwaered Agent
Samuel St.Clair II [e-mail]
Name of RapaMred Agra E ants/Address
1619 Oberlin Road 1619 Oberlin Road
Gwent LIMON AddrMs Current Street Address
Raleigh,NC 27608 Raleigh,NC 27608
Chi Stoat Zip City Stan ZIP
Tabphore 919-559-2071 Fax Number
The above lrlalmnabon ns true and correct to the best of my knowledge and belret and was provided
by me under oath(This form must be signed by the Fnancoly Responsible Person of an ndivrduat
or his attorney-in-fact.or it not an indivdual,by an officer.director.partner.or registered agent*eh
the atahorey to execute nsbtsnents for the Financially Responsible Person) I agree to provds
corrected ntormabon should there be any change in the nfomratron provided herein
5 ci.0,4.2,d 5 t- .Ltif +� vwA.r
Type oy ^° Title or Authority
) -'i �/117/ A3
Signature Date
1 It Y n� 1�11 s Notary Pubic d Ow County of
1.��1 fL—•
State d North Caroline. hereby candy thatIYl DLY Sf L At% - Wowed
personally before me the day and bang duly sworn Olaf the above form ova executed by tern.
Witness my hand and notarial sera.Pus / {day d 20 _
Notary
Seal n( f1
, SSrONO/ ' My otxrem,e:edrt expires J
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