NCC233070_FRO Submitted_20231013

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may Initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKECounty 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
NORTH CA UN NA 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 Overlook at Mount Vernon Lot 35
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Camp Side Court Latitude 35.979772137 Longitude -78.689616
3. Approximate date land-disturbing activity will commence: October 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): 30,882 sq ft/.709 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Scott Eppenbach E-mail Address [e-mail]
Telephone [phone] Cell# N/A Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
CCH RDU LLC 919-781-5225
Name(s) Telephone Fax or E-mail address
3739 National Drive Ste 128 3739 National Drive Ste 128
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
8. Deed Book No. 19064 Page No. 1070 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):
CCH RDU LLC [e-mail]
Name E-mail Address
3739 National Drive Ste 128 3739 National Drive Ste 128
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
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:
Terry Carlton [e-mail]
Name of Registered Agent E-mail Address
3739 National Drive Ste 128 3739 National Drive Ste 128
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Telephone [phone] 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.
Brittany Pinkham Accounting & Operatoins Specialist
Ty e o pri n e Title or Authority
Signature Date
I, - r , a Notary Public of the County of V\ .
State of North Carolina, hereby certify that 'fl`C4\A—av\L ( \.. A-N appeared
personally before me this day and being duly sworn acknowledged that e above form was executed by him.
Witness my hand and notarial seal, this t_9- " day of4-- , 20 ari.
,,NUW mulip,rp
r
o •'�O Tq ?,,,,,,; ry
Seal e '1-::R`
071m, Exp. I My commission expires
z` 24.2024
f�OUN .
rr,rrr 1 r!p l l 11111 U 100