NCC240277_FRO Submitted_20240201

- '- WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
ma's SEDIMENTATION POLLUTION CONTROL ACT
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No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WA 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
NORTH CAROLINA 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 calls [Zesave Lo4L s 74 t 755i 78'
2. Location of land-disturbing activity: Jurisdiction Wale COCA1 Ey
• , (Wake or Municipality)
Highway/Street5Mrnetr ¶&,yl9e{Latitude '7�f. (p(p 3 Longitude'�5,cfg
3. Approximate date land-disturbing activity will commence: 101 Z31 2-3
4. Type of development(residential, commercial, industrial, institutional,etc.): res it:tenl7a f
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): I., C((k
6. Person to contact should erosion and sediment control issues arise during land-disturbing
activity:
Name Dos Cal (.,vt(((®4+ E-mail Address tScaviii`s uncle,(. COYIi
Telephone Om ) &30-( c`/5 cell# (Ri et) 630-I R 15 Fax# ./---- --O
7. Landowner(s)of Record (attach accompanied page to list additional owners):
(kJ i14 11 !do's Inc, (qlk) 630 -(115 1olks6vl idP tvtC� rvl .
Name(s)�` Telephoned Fax or E-mail address U
'4 Worley orley Pr. qv; k)c rie or.
Current Mailing Address Current Street Address
Ra(el A Nit 2.413 2a4e(511 MC 276d 3
City State Zip City State
f
Zip
8. Deed Book No.(7'f.) ®1' 1(qO Page No. Oil 7(4 Provide a co
Part B. 06)0(44 a 012.47 pY of the most current deed.
(78)Otely22 Ol i47
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):
w{(kS &it(dens im. (NI 16kvi !amino apQwi . corer Name E-mnil Address �.J
q243 War kV Dr. 4213 t4Jorl ey pr.
Current Mailing Addr ss Current Street Address
city
Rot(eL9ti Nc 21&!3 Raletq� Nc �M6i3
State Zip City L/ State
Zip
Telephone OM) q(pR-ggqzs 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 eta e 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:
1k,j ( WtjICS wt((GsbUilde(steic cJ,9 pit> 1. COt
Name of Registered Agent E-mail Address
L.E243 W er ley Dr. 42(5 iJo (Dr.
Current Mailing Address Current Street Adds
f.ct(et�.J h Nc- VMS �4(e��G, 2771•5
City State Zip City State Zip
Telephone(4(41) OW-c{(4Z5 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.
Neil Wilks Owner
Type or print na Title or Authority
p„,,g...._____ ___
6/29/23
Signatu Date
I, Otiltkie 16,4 13yrizn , a Notary Public of the County of Liii4.1
State of North Carolina, hereby certify that La_ ,l LL 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 'VI` day of , 20 .L5
c-Akaytti arziA4P- ,7&-----,‘
• <T v,.._ Notary
£ a'F?.n f:afs
Yv�FPit� .i..,-1
�trc ;;t - My commission expires 7'--P-i✓5

7. Landowner(s)of Record (attach accompanied page to list additional owners):
MO xc. Cools-rvcho,i (,l,C ( 1' ) (o t 8-o 497 J o n ap iltoxteconSFruc-.Com
Name(s) Telephone Fax or E-mail address
tiLlo7 (JIvJc Chapel UJay '.Lto7 1IJhgje Ch�I (Jay
Current Mailing Address Current Street Address
Ra(�3b Nei 2 015 Kaiet9b Nc 27(0l5
City State Zip City State Zip
4 1 dc[i ko lla( t CVIld oUJnfr ,0 ;ri a-ton -For [Oh 75 and g
7 .
Lf 75 pB+F - ol9Lizz e ale - 0197
78 n64 - o
� 1 aNZz Paj{ o i Z17