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HomeMy WebLinkAboutNCC240538_FRO Submitted_20240223 "WM WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT ,w No person may initiate any land-disturbing activity on one or more acres as covered by the Wake Countyseimentation Unifiedcontrol Development c bbo COUNTY dn haveOrdinan been completed eefore and this approved form byand Wake Countyaccepta le Department ofand NOR III(:ARUIINA 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 NameTI(PSIe1c\ Sir 1 crtS ' -I- IN , ( IS- II11 I18- I4(0 EZ6'1 20 2. Location of land-disturbing activity: Jurisdiction ' OIPSv i I I G (Wake Co. or Municipality) Highway/Street l ,QA �Wye, Latitude3S,or-it Longitude ^ 1 g, `KP Z 3. Approximate date land-disturbing activity will commence: 1/A0 f L I 41- 02 4. Type of development(residential, commercial, industrial, institutional, etc.): }Rtctote VrrkLi 5. Total acres a disturbed or uncovered (including off-site utilities and borrow/waste areas): 1,'3 Z 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name 1 E-maila.Cl v1S Address ohi.S 6)0,{rhbrhn. Corn Telephone Cell � C' ' t t'_2t(03 p # ( l Fax# 7. Landowner(s)of Record (attach accompanied page to list additional owners): D.2, Dor n , )NIC Name(s) Telephone Fax or E-mail address �Zd g -rot11s o-CKt sR--TdSke.2o\ Current Mailing Address Current Street Address el)NQ e Ca1� I\I L r,2v LD I S City State Zip City State Zip 8. Deed Book No. 01"1nn 505 Page No. 2A c(-1 2.3 rovide 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): \-\tAoil INL 12 niiivNyhOr vis�yN --mkV 1S \id((ht, (+fon �c Name E-mail Address ZO Y `ra.11 c o� N- sasi,Ste.,Id1 Current Mailing Address Current Street Address City State Zip City State Zip Telephone R 1" I �3 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: C.T. C0(�p ra,h _ Name of Register d Agent E-mail Address I (.o O (yl r t CO ZOO Current Mailing Address Current Street Address C alp.; . �L a�[A,c City Q State' Zip City State Zip Telephone vl 1 I - U-4 4- 4'7 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. Typ or print name <- Title or Auth rity ),(Ar\ - 5- 20 Signature Date I, (-11/A.A1-- m 57Si(v(o , a Notary Public of the County of $-1 9'-- State of North Carolina, hereby certify that]gC(1 M. 'DAVI'S appeared personally before me this day and being duly sworn acknowledg d that the above form was executed by him. Witness my hand and notarial seal, this 5 day of , 20 02 ! P -.tnors, `�„V00 ,�n�ssioNF114 ( ,$ � � Notary NO RY PUBLIC My commission expires o2 /6 40Z-R %,4VA RY✓' t, c013N4...‘