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HomeMy WebLinkAboutNCC233262_FRO Submitted_20231102 ICIPIIR WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM r+►•""� SEDIMENTATION POLLUTION CONTROL ACT W� No 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 NORTH(.;,RO,,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 6/7t.,d 1.11r //„„J j: t, 2. Location of land-disturbing activity: Jurisdiction GJalce. (',o (Wake Co. or Municipality) Highway/Street rp^/ µvh kind Latitude 31c. Ot.Ca 9 Longitude -7$,,fig 2c, 3. Approximate date land-disturbing activity will commence: /D - 7_S- -Z4)L3 4. Type of development(residential, commercial, industrial, institutional, etc.): e.eSlaI 5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): p q q 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name %a. 3,kelNd" E-mail Address et L�l® I>,l.le,` ,u,.,fv,,.4,a,,,,c.r. ,,_e1' Telephone AM-53o -OI' -7 Cell# - Fax# -- 7. Landowner(s)of Record(attach accompanied page to list additional owners): ?_Cdt.G (jc p.. 1-61to t tee_ 918.-S3o-019 7 44.8- v e/ fv ,l�u,rw i Name(s' Telephone Fax or E-mail address ( 736: cells (/alm, 241 ..Sti;k. 3Ur — Current Mailing Address Current Street Address City State Zip City State Zip 8. Deed Book No. Ig 71 3 Page No. fl 48 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): i0lu5h C.�.,him" s X_ Li-@'_ra t;Lsi"t�,hAti,h.5„�,3 .�1— Name E-mail Address (.t734 cells Nwyr - eat Sol-e_ Tno Current Mailing Address Current Street Address 1241651/• An.--- a"! c.f.1 S — City State Zip City State Zip Telephone QIY-S. -019-) 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: J tPe)01114 (Ai. onpsd/1 t►,M (ct 1(41.11'br,inonme t•rut— Name of Registered Agent E-mail Address ("73Cs cal)s J .vwu 0.J S.Ak Too Current Mailing Address Current Street Address ga eije% dUC, c97LL.1S City State Zip City State Zip Telephone q . <53c)- bI° 7 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 or print name Title or Authority /O -tts— Z3 Si ature Date I, Ailbek/At L:11/! , a Notary Public of the County of ,hr State of North Carolina, hereby certify that / 'mod /A/7 � appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my �t ` e jts /G day of a,�j,�� ,20 y �'al seal,this %'` a .ni.fBgoy...... a /I'p Os ref ��,! ®T Allr. f. .: otary 11A.5 Oek-\ , My commission expires a-5Ic 1-7 toot o u tt`;`t��`�`