NCC233420_FRO Submitted_20231116

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W� No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Countysedientation Unified contr Development an ve Ordinance be obomol pl ha been completedefor and this approvedfrm byand an Wake Countyaccepta le Depaer oast_
sionment ofand
COUNTY
NOR 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.
Lot 13 Overlook
1. Project Name
Wake Co.
2. Location of land-disturbing activity: Jurisdiction (Wake Co. or Municipality)
1520 Lake Adventure Ct 35.98226 -78.69481
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence: 11/15/23
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):_ 0.55
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
James Denton [e-mail]
Name E-mail Address
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Future Homes by Jim 919-363-4111
Thompson, Inc
Name(s) Telephone Fax or E-mail address
1105 Classic Road Same as Mailing
Current Mailing Address Current Street Address
Apex,NC 27539
City State Zip City State Zip
BM2023
8. Deed Book No. Page No._ 116 rovide 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):
Future Homes by Jim
Thompson, Inc
Name E-mail Address
1105 Classic Road Same
Current Mailing Address Current Street Address
Apex NC 27539
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:
Jim Thompson [e-mail]
Name of Registered Agent E-mail Address
1105 Classic Road
same
Current Mailing Address Current Street Address
Apex NC 27539
City State Zip City State Zip
Telephone [phone]
P 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.
Jim Thompson President
Type or print name Title or Authority
10/10/23
Signature Date
I, Kt e rly lowi 5 , a Notary Public of the County of W c,
State of North Carolina, hereby certify that vyt -Th �5 py► appeared
personally before me this day and being duly sworn acknowledged that he above form was executed by him.
Witness my hand and notarial seal, this I 0441day of ba406r_r , 20 23
�ry%�s Notary
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ti Cotrrnissi0n Ex•lres 101 027 N My commission expires 10/ i 1 /2„021