NCC232818_FRO Submitted_20230918

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
D bb erosion
COUNTY sedimentationCountyUnified control planevelopment haveOrdinance been completedefore and this approved
form byand an Wake Countyaccepta le Department ofand
Nos„i CAROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name 31 Sanctuary at Lake Wheeler
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 2917 Frances Marie Lane Latitude 35.702952 Longitude -78.690206
3. Approximate date land-disturbing activity will commence: 08/01/23
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.41
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Robert Russotti E-mail Address [e-mail]
Telephone N/A Cell# 919-360-6099 Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
SANCTUARY PARTNERS LLC N/A N/A
Names) Telephone Fax or E-mail address
610 PRESIDENTS WALK LN 5804 LAKE WHEELER RD
Current Mailing Address Current Street Address
CARY NC 27519-6851 RALEIGH NC 27603
City State Zip City State Zip
8. Deed Book No. 19051 Page No. 0825 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Exeter Building Company LLC [e-mail]
Name E-mail Address
900 Ridgefield Drive 900 Ridgefield Drive
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number N/A

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, 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
Disturbance Permit:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form 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.
Alex. der Yost Managing Member
T ,.e or p int ay e Title or Authority
08/29/23
/ gnatu : Date
Jeremy Gage , a Notary Public of the County of Wake
State of North Carolina, hereby certify that Alexander Yost appeared
personally before me this day and being duly sworn acknowledged that the above form was exec ed by him.
Witness my hand and notarial seal, this 29th day of August , 20 23
�� - - �- - � - - - - � Notar
JEREMY GAg� I
Notary Public- Nort'ti%i olfna ( Myommission expires �{ I3 2 u
Wake County ( •
p I 1
My Commission Expires Apr 3, 2024 1