NCC233481_FRO Submitted_20231122

13.111 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
'111111111 SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land disturbing activity on one or more acres as covered by the Wake
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
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 (. )1 .i , i 1 1 1 ::, I`
1. Project Name
2. Location of land-disturbing activity: Jurisdiction WAKE (Wake Co.or Municipality)
Highway/Street-RARTON VIEWI CT Latitude_35.9296>>5_Longitude_-78.682840
3. Approximate date land-disturbing activity will commence: Dr C FMBER 23, 2023
4. Type of development(residential,commercial,industrial,institutional.etc.): RESIDE Ni IAL
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):_ 0 5 A(11
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name VAICI IAV JAIN E-mail Address V1(1'SHAILI-IOMES.CONI
Telephone Cell# 1 l� E'3' 0681 Fax# [phone]
7. Landowner(s)of Record(attach accompanied page to list additional owners):
SNAIL CONSTRUCTION 919-728-4801
Name(s) Telephone Fax or E-mail address
2841 PLAZA PLACE 2841 PLAZA PLACE
Current Mailing Address Current Street Address
RAl F I(;H NC 2761? RALEIGH NC ;76i1 2
City State Zip City State Zip
8. Deed Book No. B.M. 201 / Page No. 658-663 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):
SHAIL CONSTRUCTION LLC .JAINM@)SHAILCONSTRUCTION.COM
Name E-mail Address
VAIBHAV JAIN 114 1-EALIGH I- LANE
Current Mailing Address Current Street Address
(,;PY NC Chl.l' NC 27513
City State Zip City State Zip
919-633-0601 919-882-9077
Telephone 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.
VAIRHAV IAIN MANAGING MEMBER
Type or pr. name Title or Authority
to 0 .�
Signal a Dat
I, I<olfe EsmQralda PcI vcr.e7a Notary Public of the County of JohnSt ) h
State of North Carolina, hereby certify that V 01 1 b h of V J Gt r h appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this 3rd day of 0 CtD h-2 r ,20 23
f ERALD
� q,4 Notary
"ortanat 4.* !G s
0,93 My commission expires__ 0 ( _21_J2.lp
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NOTARY r+ ?
1. PUBLIC
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