NCC232819_FRO Submitted_20230926

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
sedimenta Unifiedon Developmentcontrolplanhave Ordbe an
COUNTY tien completedinancebefore andthis approvedform byand an Wake Countyaccept le Departerosionment ofand
NORTH C:AROLINA 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 Ce .AHAr%5ro,JE, G LEIJ
2. Location of land-disturbing activity: Jurisdiction i )16116 . (Wake Co. or Municipality)
Highway/Street GRANAMsrao Rt., Latitude ]S.72 8.304 Longitude -71g,48122Z_
3. Approximate date land-disturbing activity will commence: 0 7/0//2 o Z Z_
4. Type of development(residential, commercial, industrial, institutional, etc.): (2.ES1oEg rIAC.
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 9.S S'
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Z t k- J i eh L_ E-mail Address STEELSP e-/,4/./oo.LoP\
Telephone 919- 779-/B SS Cell# Fax# 919--714-/G G/
7. Landowner(s)of Record (attach accompanied page to list additional owners):
VA$r ►JTi- Surf IL. L110 (& I `M-119-/Ea( t_AVF1.N1006 rd GrA,�,co�
Name(s) Telephone Fax or E-mail address
)08 I-1Ert&Gwaiy razes! PE.
Current Mailing Address Current Street Address
R Pet-G/G, Z 760 1
City State Zip City State Zip
8. Deed Book No. 94 it, Page No. f3 24 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):
Arvin Lavani [e-mail]
Name E-mail Address
108 Hemingway Forest Place
Current Mailing Address Current Street Address
Raleigh NC 27607
City State Zip City State Zip
Telephone [phone] 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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip 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 Certificate 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 Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
AR L.z/v.� �-. 2,4410e.ew, .
Type or print name Title or Authority
Lf--2S-2o22, ,
Signature �Gv Date
I, C \ul /0a.V L' a Notary Public of the County of LPJc,4
State of North Carolina, hereby certify that / tt b LI CL ,d . d,ct U a 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 5*L-day of ( ,,,v2. , 20 a
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My commission expires 'Lip•
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