NCC233719_FRO Submitted_20231215

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ICW" WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 4j11YC)01-3
SEDIMENTATION POLLUTION CONTROL ACT
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WAKENo 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
CO U NTY sedimentation control plan have been completed and approved by Wake County Department of
„ „s 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 LOT a OU(( )4:.k. «1 iv } k'er,l'z..J r LA- )C 3
/
2 Location of lend-disturbing activity Jurisdiction W R I4/Z_ (1Naice Co. or Municipality)
-1a4y Highway-Street Si Ic, AI- ) i tier Latitude 3C. 4I �_' Longitude — 1,5'. (Al o)
3. Approximate date land-disturbing activity will commence N«i.,11.. D•'"t).?
4. Type of development (residential. commercial, industrial. institutional. etc.). Ci), Ae.--44 At/
5 Total acreage pdisturbed or uncovered (including off-site utilities and borrow/waste
areas) . 14i
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name -)N-4,4k A Or icy E-mail Address i AT St`t � 0 . I ,' b.a� .t. . M Lo
Telephone 1141 - (P (09 - ) 1 Y Cell# II t 1 - L; VI • aC) Faax# i14
7 Landowner(s) of Record (attach accompanied page to list additional owners) ` !ie A Db1}IOt I ' I).—
(r[p1 L.„„e g�;,,1 art I L,u_ g Icj - iplvel- J S1 3 T j &s(Ay I,pot u„Ide , ....
Name(s) Telephone Fax or E-mail address
.S.`\ CA LAIR., I-- I,Lr}--r Sr 9 C AI-1k`. u-44- tu41-
Current Mailing Address' Current Street Address
City v State Zip City State Zip
8. Deed Book No_ G I'll 3 Page No &.'L .. 33 `1 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).
Name �} E-mail Address '
S�(1 LA 1 1kl-A/1v IL t&A-y S -r, L-44-&(S/)+ii LM-4--y
Current Mailing Address Current Street Address
City V State Zip City State Zip
Telephone I I ct- OCei - JO '1 Fax Number /J 1l

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 ^f E-mail Address
1\ p
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
ib) If the Financially Responsible Party :s 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
�
7 4Txy J ArSe M( ,4 I r},I. e ��,�� tc�c'1`� . (�
Name of Registered Agent E-mail Add s
Current Mailing Address Current Street Address
City J State Zip City State Zip
Telephone 11 • �, t • , Al Fax Number IN%[1-
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.
.,�: ��,�U .� rs�•� IN\
Type or pint name Title or Authority
_ it I s
Signature Date
I. KY t 7:.Prt tIX:n t a Notary Public of the County of V\l
State of North Carolina hereby certify that r appeared
personalty before me this stay and being duly sworn acknowledged that the above•orm was executed by him
Witness my Nana aria notarial seal. this day of f'1 ►! -' , 20
- 174\ ,Af."1 RA,-%(-.\
KfISHAWNA BROWN ' Notary
' public, North Carol• :,
Durham County My commission expires i:)\ 1 l
•i. Commission Explre

DO JD4itr"-
WAKE illIliiiiIIPI COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM / -OD0 h\)'v'11
SEDIMENTATION POLLUTION CONTROL ACT eft;
rWAKE No person may initiate any land-disturbing activSy on one or more acres as covered by the Wake
illillCounty 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
�r,�,�������� Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable. place NIA in the blank ) L. C2- D S c-A L �A VACvN f
Part A.1. Protect Name �OO;4-4 � L Cr-:3c)ef
�ti�� t IL Pfr
L G 0 - 1�aea
kjakr4.4
2. Location of land-disturbing activity: Jurisdiction (Wake Ca or Municipality) p1.1j(.
Highway/Sl refit Latitude Longitude-- r,
3 Approximate date land-disturbing activity will commence: _--
i
4 Type of development(residential. commercial, industrial, institutional. etc )
5. Total acreage disturbed or uncovered ding off-site utih' and borrow/waste
areas):
6. Person to contact should erosion a i ediment control issues arise bring land-disturbing activity:
Name r E-mail Address
to_hone Cell St- Jr Fax A (t 1
7. Landowner(s) of Record (attach accompanied page to list additional owners). ���-��� �--
g►-Pt�t'�Sr�S LCctk bt,1=.► ,�{� L�� `1I`i - 341 - (,`ft s c►fc, .)f AMrcui sci .c,.M
Name(e) Telephone Fax or E-mail address
(1:'l Gil$. 91,4 S 7 �; • .. t�'► 7
Current Mailing Address Current Street Address
3 .
;1t�.N‘- N�- State)--1(a tit_ �- 1..� `I
City State Zip city ' State Zip
8. Deed Book No C 01 3 lc Q Page No. I 1 1 — Provide a copy of the most current deed
Part
te �
— - — C I 7 3 � = f,
1 Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive Iist of all responsible parties on an attached sheet. Include requested information)
Name E-mail Address
Current Mailing.Address Current Street Address
City State Zip City State Zip
Telephone Fax Number