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HomeMy WebLinkAboutNCC240798_FRO Submitted_20240319 OP. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT WAK E No 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 ,.,,�.�,t,,,� 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 Kreitlow Residence 2. Location of land-disturbingactivity: Jurisdiction Wake County y (Wake Co. or Municipality) Highway/Street 4925 Foxridge Drive _Latitude 35.7035 Longitude -78.7220 3. Approximate date land-disturbing activity will commence: March 25, 2024 4. Type of development(residential, commercial, industrial, institutional,etc.): single family residential 5. Total acres a disturbed or uncovered (including off-site utilities and borrow/waste areas): 0.99 acre 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Adam Marlow, Don Pegram E-mail Address adamm@rufty.com, Don@Rufty.com Telephone 919 460 8550 Cell# 919 616 2392 Fax# 7. Landowner(s)of Record(attach accompanied page to list additional owners): Kelly & Kimberly Kreitlow, Trustees 919-605-4999 kelly.kreitlow@dynamicdevices.com Name(s) Telephone Fax or E-mail address 710 Eastridge Drive Same Current Mailing Address Current Street Address Apex NC 27539 City State Zip City State Zip 8. Deed Book No 019257 Page No. 1945 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): Kelly and Kimberly Kreitlow kelly.kreitlow@dynamicdevices.com Name E-mail Address 710 Eastridge Drive same Current Mailing Address Current Street Address Apex NC 27539 same • City State Zip City State Zip Telephone 909-605-4999 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: N/A 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: N/A Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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. I�c1ll� �trej �La Owner Type or print me Title or Authority 2/ Zy Signature Date I, L O-Q ) (IJ VCLL , a Notary Public of the County of (VI k ._ State of North Carolina, hereby certify that ,l � (1,�,� 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 1 day of Rhfuctay ,20 1L1 L4Q,b(. ratA<CL Notary Seal ) My commission expirespc -r&O LAUREN M KAY Notary Public Wake Co., North Carolina My Commission Expires April 20,2027