NCC240377_FRO Submitted_20240212

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WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
"��„CAROL to n 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 (0S00 CENTUI ley 0 WIC
2. Location of land-disturbing activity: Jurisdiction WAKE (Wake Co. or Municipality)
Highway/Street Ce"-dry DAle. Latitude 3 S•`I C"0 2- Longitude - 1 a• (o I i
3. Approximate date land-disturbing activity will commence: 0%/ 0%
4. Type of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1. 2.9
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name ICI Le 370i114Sota E-mail Address I E 4 K A.t.C%OtiCUSitt•'11.1ameg. t4ET
Telephone 016)✓30 0111 Cell# —' Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
ZRLEIG4'R CIASToi 12yI,E1GHCU5134A1 4Es,
Name(s) Telephone Fax or E-mail address NET'
L, 13(D Fhu.s ®F NEvISE R .0 Sre 300
Current Mailing Address Current Street Address
QK4LEfCH NG 2"1(t7I5
City State Zip City State Zip
8. Deed Book No. vaioi Page No. Q$(9 2 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):
IZWLEI6 1 CIAST6M fiOMES IBC Kvie- 12 t1.El i-1 COsTbM+106Ae-c. NC-T
Name E-mail Address
o"13 FAL-,S of NEUS6 12D Sie SOO
Current Mailing Address Current Street Address
V2ALEI611 21u15
City State Zip City State Zip
Telephone (110) 53C7- 0 iql 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:
TsM Mil 1 THOWSON a '1'IM& 12.1211-51Gt1GA1$`pMt16NtEs. IVET
Name of Registered Agent E-mail Address
G 13(6 FMtl tc OF N Ev1 S E PD S E' 300
Current Mailing Address Current Street Address
kifi LE:tGi-I t NC 21415 ---
City State Zip City State Zip
Telephone ci t ._ 53 o - 0 11l 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.
TOM ill OM I'Sa,I p12ES it7 7
Type or print name Title or Authority
�,.,f
11. 1 2 t / 23
S' natu Date
I, . icw/'��h(�/ Ir , a Notary Public of the County of .01/44ie
state of North Carolina, hereby certify that "fit ,�� w l appeared
personally before me this day and being duly sworn acknowledged`t'hat-the above form was executed by him.
Witness my hand and notarial seal, this 2-1 day of ea , 20 g,
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