NCC233015_FRO Submitted_20231009

"WI 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
Development Ordinance before this form and an acceptable erosion and
COUNTY sedimCountyentationUnified control plan have been completed and approved by Wake County Department of
„ ARC„N 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 CUi /}3 C zfSC,Fk)---
2. Location of land-disturbing activity: Jurisdiction 4i ( tczy (Wake Co. or Municipality)
Highway/Street Mg Lyr?4 !� Latitude 56,evlecv /Longitude _ 7$, lo757Z0
3. Approximate date land-disturbing activity will commence: 3/s�r 2073
4. Type of development(residential, commercial, industrial, institutional, etc.): ,ec1 pf-N74-L-
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): • 94 J4 c_
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 57A[ .,oc/W/tt'2— E-mail Address ST Z; 'Q ¢/e.,
Telephone 71 9 -- Q-/p74, Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
JfL /4I=fa 5— ��-, Pik- 6/c'/97(e P�Z�o° ojrn /<<4
Name(sl' Telephone Fax or E-mail address
39E ' / ,E /4 2&. 3a'6.
Current Mailing Address Current Street ddress
Wif u2�Clrr AK Z7517 Ii/4t, 77sW7
City State Zip City State Zip
8. Deed Book No. I9'237 Page No. 0177 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):
$ ii, / — J 2 ? g 5)4-)4/Z. l�
Name E-mail Address
7-1-Pff /44-1 - Pi? /1-10 /4i(-1 -7 .1)
Current Mailing Address Current Street Address
'lc Z75-i 7 1 C7- r A/C- X)7
City State Zip City State Zip
p
Telephone P/Q/ 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.
5-1 DF
Type or i Fe Title or Authority
2- 22- 7o23
Sig a re Date
I, Octsl'avannc. YV ilic6vlck. , a Notary Public of the County of Wa ILt
State of North Carolina, hereby certify that 56nIell .06`.1 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
kid
Witness my hand and notarial ,41k day of .bruq ii , 20 2 3
,7 (PG .�: U Notary
Seal : N N vg\. :
'%0., N`b �.:, My commission expires 9��$I2G 2 y
'IKE CO
,'lli,,,,,,,,,,,,,,,`'