NCC240174_FRO Submitted_20240118

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
Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentatiCountyUnifiedon control plan have been completed and approved by Wake County Department of
NOR III l ARUHNA 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 12 Shinleaf Estates
1. Project Name
2. Location of land-disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street 7644 Falls Creek Lq_Qmtude 35.988 Longitude -78.654
3. Approximate date land-disturbing activity will commence: 12/13/2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): .495
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kimberly Walters E-mail Address [e-mail]
Telephone Cell# 919-345-1924 Fax #
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Stellar Blu Construction, Inc 919-345-1924 kimberly@stellarbluconstructior
Name(s) Telephone Fax or E-mail address
8601 Six Forks Rd Suite 400 8601 Six Forks Rd Suite 400
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
8. Deed Book No. 19470 Page No.2481 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):
Stellar Blu Construction, Inc [e-mail]
Name E-mail Address
8601 Six Forks Rd Suite 400 8601 Six Forks Rd Suite 400
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
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:
Kimberly Walters [e-mail]
Name of Registered Agent E-mail Address
8601 Six Forks Rd Suite 400 2600 Glenwood Ave, Apt 311
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] 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.
Ki erly Walters President
Typ or pr. nam Title or A hority
/ 0') /202Z/
ature Date
I, Ja6o3 Aide, o^ , a Notary Public of the County of We.., 1-14
State of North Carolina, hereby certify that �C,�+IP?,IY �✓• (ire5 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 - day of . 41 KAfy , 20 a
t1 JACOB ANDERSO .1oary
Seal f,L . Notary Public J
North Carolina My commission expires der If, 10./7
New Hanover County