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HomeMy WebLinkAboutNCC233414_FRO Submitted_20231121 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 County i Deec be acceptabo COUNTY sedimentationUnif ed controlv planlopment haveOrdinan been completedeefor and this approvedform byand an Wake County le Departmenter sion ofand NORTH CAROL!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 Wendell Falls Flex Construction Documents Wendell 2. Location of land-disturbing activity: Jurisdiction (Wake Co. or Municipality) Wendell Valley Boule 35° 79' 09" N 78°25'47"W Highway/Street Latitude Longitude 3. Approximate date land-disturbing activity will commence Summer 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) 40.12 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Tanya Matzen E-mail Address tanya.matzen@brookfieldpropertiesdib Telephone(919)951-0718 Cell# (919)521-2583 Fax# 7 Landowner(s) of Record (attach accompanied page to list additional owners) Nash Wendell Falls, LLC (919)951-0718 Name(s) Telephone Fax or E-mail address 13777 Ballantyne Corporate Place, Suite 500 Same as Mailing Address Current Mailing Address Current Street Address Charlotte NC 28277 City State Zip City State Zip 8 Deed Book No.015478/016648 Page No 01623/00594 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): Nash Wendell Falls, LLC tanya.matzen@brookfieldpropertiesdevelopment.coa Name E-mail Address 13777 Ballantyne Corporate Place, Suite 500 Same as Mailing Address Current Mailing Address Current Street Address Charlotte NC 28277 City State Zip City State Zip Telephone(919)951-0718 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_ byme 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. Tanya Matzen VP, Operations Type or print name Title or Authority Signature Date 1 1, A- vt , a Notary Public of the County of a v'CLIACid-C State of North Carolina, hereby certifythat IC� 1 •1ct kla_tZ�4/1 appeared personally before me this day and being duly sworn acknowledgJl that the above form was executed by him. Witness my hand and notarial seal, this 1t-\ day of .6 h e t/ , 20 Z" 1C4Gr�� ' N ',, Notary r - ",Kc A R y My comr'n.gsion expires i;c/ l_ /ZQ?5 "U3 - , .o,��Al? �CO ``,.,,,��