NCC240396_FRO Submitted_20240214

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 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 Sanctuary at Lake Wheeler Lot 25
2. Location of land-disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Theresa Eileen Way 33.849560 77.973846
Highway/Street Latitude Longitude-
3. Approximate date land-disturbing activity will commence: 01/20/2024
4. Type of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.45
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Michael Ward Name E-mail Address [e-mail]
Telephone [phone] Cell# 919.669.3005 Fax# [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Amward Homes of NC Inc 919.319.6162 919.319.6131
Name(s) Telephone Fax or E-mail address
133 Triangle Trade Drive Same
Current Mailing Address Current Street Address
Cary NC 27511
City State Zip City State Zip
8. Deed Book No. 19475 Page No. 1622 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):
Amward Homes of NC, Inc [e-mail]
Name E-mail Address
133 Triangle Trade Drive same
Current Mailing Address Current Street Address
Cary NC 27511
City State Zip City State Zip
Telephone [phone] Fax Number 919.319.6131

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:
Robert A Brady [e-mail]
Name of Registered Agent E-mail Address
160 Iowa Ln Ste 104 Same
Current Mailing Address Current Street Address
Cary NC 27511
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.
Michael Ward President
Type or print name Title or Authority
01/09/2024
Signature Date
I, n+1 A ttLA'rS , a Notary Public of the County of 1&44-t�"`—
State of North Carolina, hereby certify that li--1 eL-An/A-2- 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 , 20
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