NCC250508_FRO Submitted_20250225

EVIIII WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may inibate any:and-disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUN�I Y sedsmentat-,on control plan have been completed and approved by Wake County Department of
��,,,,,_�,,,,1,111
Environmental Services. Water Quality Division (Please type or print and, if the question is not
applicable, place NIA in the blank_)
Part A.
II f
1_ Project Name l� l.aA."eI I C Lp-,ic G- - 3 �it?k eS Ccaltiir x-0-
2. Location of land-disturbing activity: Junsdsction bake (Wake Co. or Municipality)
Highway/Street So'''S t D?k...e (I Latitude 35_9130 Longitude - 78. 3 T
3 Approximate date Land-dtsturbing activity will commence: 2• Z -2 C.
4. Type of development(residential, commercial, industrial, institutional, etc.): Rh:,ir,.-lA
5 Total acreage disturbed or uncovered (including oft-site utilities and borrow/waste
areas): . I I
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name B : -C,n„r, E-mail Address
Telephone NI) .1 d Cell# ,r/ i 37q`( Fax# 1'.)f 14
7 Landowner(s)of Record (attach accompanied page to[�'list additional�oJwners): (�
t./'C I/ / eJe)y:,, LLC c'_l Z91 3 ,, P F ,
Name(s) / ' Telephone Fax o�E-mail address
I21Z R- .-r,S /=l1 rc4
Current Mailing Current Street Address
(.� 719
City / State Zip City - State Zip
8, Deed Book No.6 I313 rJ Page No.Q003/ Provide a copy of the most current deed
Part B.
1. Person(s) or firm(s) who are financialty responsible for the land-disturbing activity (Provide a
11...i.
comprehensive list of all responsible parties on an attached Sheet Include requested information):
TA-•-,.-, II DDv1• LL i 1)i;4! �?/4ev�[r dei.e/;J711t,5-t�7
Name E-mail Address r
12IZ R-� ..11- ,n Al/f l
Current MaiiiQAddress Current street Address
t)C- 27It'1 iv] 14
City / State Zip City State Zip
Teicpnone 1 /I 1 Zi 13-?sY Fax Numbe: t)f A

2. I,a) It 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
I I,
ti
Name E- it dress
Current Mailing Address 1 I k Curre ee cidrrss
City Sr Zip ity State Zip
Telephone - Number
(b{ if the Financially Responsib e Party s 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 addressor the Registered Argent
\ IL.
Name of Registered Agent ii E- Acidness
1
Current Mailing Address Current •treet Add ,137„
City State City t r ' Zip
Number 1
The above information is true and correct to the best of my kn• ledge and belief and was provided
by me under oath (This form must be signed by the Financially • - •*risible 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.
17 -zeke, O'C.,,„eik tthM r.fJer� KC.c et'
Type or priyitname Title or Auth my
'
4
Signati.we, Date
I. 4_.( k L _( , a Notary Public of the County of 1�V 0. -
State of North Carolina, hereby certify that 1 U v i c`p k iA( (._ ` appeared
personally before me this day and being duly sworn acknowledged that the above form_w_as executed by him.
Witness my hand and notarial seal, this 14t day of _ 1 %l�•�C{v .- _-1 2o G�->
_ �p'C A 1�y 1 Notary
Seal: Ll—(4•-z-C -7
My commission expires
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