NCC232872_FRO Submitted_20230922

"WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo 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
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
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 £ ' te.kX fibre,
2. Location of land-disturbing activity: Jurisdiction Li - . (Wake Co. or Municipality)
Highway/Street /4 i 1e.S bu r T 2(0 Latitude 357 'MI cR 2 7 Longitude -78 . S`/yo 7.5-
3. Approximate date land-disturbing activity will commence: q-/- ZoZ3
4. Type of development (residential, commercial, industrial, institutional, etc.): 2csil -&.,
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): O. 'I
6. Person to contact should/I erosion and sediment control issues arise during land-disturbing activity:
Name nbne Morri3 E-mail Address I)rrtorri5e flirt cri 5.Csn
Telephone Cell # qif-3y5-o575" Fax# r--
7. Landowner(s) of Record (attach accompanied page to list additional owners):
/ J /7201-1-►3 6's45*: T•?c 1 19-- 3Y,fc5S/5/ hmerii5 eIi_"� ►ncrci5.cam
Name(s) Telephone Fax or E-mail address
(-. (. . 3o,>( leg 5-3 i 0 1. eft' rd CIAL4a 54.;t._ io i
Current Mailing Address Current Street Address
- i - N6- o?74,2y (c, '749/5—
City State Zip City State Zip
8. Deed Book No. Z4=03 Page No. S 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):
Name E-mailn Address 4
Current Mailing Address Current Street Address v "
--ee--Pei<‘ NL 07(0 Zc�.Q�i { _ �7� �
City State Zip City State Zip
Telephone 41/'e/-3 7' Ds/4/ Fax Number

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:
4JT /n. y-r%s G.lr..sfruc 'r4 Z - 1-2•97Gr is,21?j ln,Or-r;s.r c›-y.
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone GJ1//- 3 5.% F7$7 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 Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
11-\arNi)549..... J'L Fbr rtl PZL& -\1--hi-rn,t95a.-LC-' Y"11�T)p5Th./uw AC.. Cam-.
Name of Registered Agent E-mail Address
/1;S� .Rilcra,irc A;tMT Sw;fe.Zoo -3ew1-4..-
Current Mailing Address Current Street Address
._'(z.n ivL ,?7.s'Il ,
City 7 State Zip City State Zip
Telephone c-//Q - Y/7 --S 3.5) / 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 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.
Type 7-r+nt na Title or Authority
/ -23 - 2az3
Signature Date
I, M ci ii lien -( C lOs tttii , a Notary Public of the County of \AJii�C l
State of North Carolina, hereby certify that !-kink V lar"►h appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 0Z3(�day of , 2001.3
MARY ELLEN POTANOVIC Notary
Notary Public, North Carolina
Sake County
My Commission Expires My commission expires (6 AOAg
June 15,2028