NCC240344_FRO Submitted_20240209

"WI 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 de bb
COUNTY sedimentationCountyUnified controlev planlopmen haveOr beeninanc completedefore and this approved
form byand an Wake Countyaccepta le Departmenterosion ofand
NORTH CAItC)I INA 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 Willow Landing Lot 49
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 1705 Willow Landing Way Latitude -78.694 Longitude 35.579
3. Approximate date land-disturbing activity will commence: 2/22/2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.72
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jimmy Gaskins E-mail Address [e-mail]
Telephone [phone] Cell# 919-868-5391 Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
KB Home Raleigh-Durham, Inc. 919-768-7988 N/A
Name(s) Telephone Fax or E-mail address
1800 Perimeter Park Dr., Ste. 140 Same
Current Mailing Address Current Street Address
Morrisville NC 27560
City State Zip City State Zip
8. Deed Book No. 019501 Page No. 00330 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):
KB Home Raleigh-Durham, Inc. [e-mail]
Name E-mail Address
1800 Perimeter Park Dr., Ste. 140 Same
Current Mailing Address Current Street Address
Morrisville NC 27560
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
Doug Schwartz [e-mail]
Name E-mail Address
1405 Willow Landing Way Same
Current Mailing Address Current Street Address
Willow Spring NC 27592
City State Zip City State Zip
Telephone [phone] Fax Number N/A
(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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Ste. 550 Same
Current Mailing Address Current Street Address
Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number Account#: 7227849
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.
Doug Schwartz Division President, KB Home Raleigh-Durham, Inc.
Type or print name Title or Authority
CLQISignature/ Date
I, , r. '(\ Q 0\�C cam*— , a Notary Public of the County of r." bht\Sk,,,,\
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowlgdged that the above form was executed by him.
Witness my hand and notarial seal, this \cr, day of�u.,nve,,,c-v\ , 20 (()L\
ipAN- \d
Notary
Seal ERIN N POLLOCK
NOTARY PUBLIC My commission expires-S,J,r
Johnston County
North Carolina
My Commission Expires June 17, 2024