NCC240266_FRO Submitted_20240130

WWI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
�Vr No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKECounty 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
NORTH C, ,,I �,, 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 f7012eycu +f Z. Ahc7/is/q Z. ols I, 6 I t b 3
2. Location of land-disturbing activity: Jurisdiction My u...lkG (Wake Co. or Municipality)
Highway/StreetB/a cA$p cc Wp7Latitude35 554'90 Longitude 78. 6 9 3190
3. Approximate date land-disturbing activity will commence:4. Type of development(residential, commercial, industrial, institutional, etc.):Resider;71i i
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 2.Z27,
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Andy ClaW"ice rd E-mail Address 4CraW77ordEeas7Iwoodhow►eS. co.•i
Telephone [phone] Cell# 9/9-#2 7-2 962 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
,g STwood io,r,cs 074/Qa/c,4LL C- 9/9-758-8208
Name(s) Telephone Fax or E-mail address
2 85 7 W es7<Po.-/ Kc7.
Current Mailing Address Current Street Address
CA rio AteA/G Z8208-3 V7
City State Zip City State Zip
8. Deed Book No.D/6 q5 Page No./528 4521 Provide a copy of the most current deed.
Part B. 4/6 329 .54,9-550
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):
Ea-Si-wood Alo.•Ie.c oI A/c,' LLe 154ewai71ce4S71w00dA es. co',
Name E-mail Xddress
2857 W e s Ipo i74 Ira . .$$TM1E
Current Mailing Addrbss Current Street Address
Gtiar/o 714e A/e, 28208 -36 y 7
City State Zip City State Zip
Telephone 7, 0 y-399-y(63 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:
Es1wooa//lei*,es of lea/e/f4 LLG •,Lc war,fCveas/waociLjo,sfes. co••-r
Name E-matt ddress
7/e/ Crc.cc%,00r ,Pal Sithta//S s,41e.
Current Mailing Address Current Street Address
/l a/e�`i NC- 2 7�/-S
City G State Zip City State Zip
Telephone �/9-756'-8Z 8 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:
TOScpf! .
_151e14,a 71-e e a,S7IW a ciAo 0.1 c.f. cow
Name of Registered Agent -mail Address
285 7 Wes cot *Kd
Current Mailing Address Current Street Address
CLiai/o e NC- 28208-3697
City State Zip City State Zip
Telephone 71' -399-4Ig63 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.
/`!wall Craw-foic✓ V%cc presiu'caf'
Type or print name Title or Authority
.05/2y
Signat Date
I, 13 ra.J , a Notary Public of the County of WZ
State of North Carolina, hereby certify that And/ CPOW(u�ci 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 (o*day of latt(A0411 , 20 24,
1 j1wj
Notary
Ecal $II$/.20aq
LAUREN B MATAS My commission expires
NOTARY PUBLIC
WAKE COUNTY, N.C.
My Commission Expires 08-18-2024