NCC216307_FRO Submitted_20211118

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHiP FORM
w�= ATM SEDIMENTATION POLLUTION CONTROL ACT
WAMNo 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
NOT]I CARO;,NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name
2. Location of land -disturbing activity: Jurisdiction Town of Kni htdale (Wake Co. or Municipality)
Highway/Street smithfield & Mailman Roads Latitude 35°46'30,6"N Longitude 78°28'09.4"W
3. Approximate date land -disturbing activity will commence: September 2021
4.
Type of development (residential, commercial, industrial, institutional, etc.): Mixed -Use
5.
Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 63.0 acres
6.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Charles Hassin er
E-mail Address. charles(@-crhassingerconsulting.com
Telephone [phone] Cell # Same Fax # [phone]
7.
Landowner(s) of Record (attach accompanied page to list additional owners);
VILLAGE GATE AT KNIGHTDALE LLC
585-465-0099 NIA
Name(s) SMITHFIELD PUD LLC
Telephone Fax or E-mail address
8480 HONEYCUTT RD STE 200
8480 HONEYCUTT RD STE 200
Current Mailing Address
Current Street Address
RALEIGH NC 27615-2261
RALEIGH NC 27615-2261
City State Zip
City State Zip
8.
Deed Book No. 018553 Page No.
01432 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):
VILLAGE GATE AT KNIGHTDALE LLC
[e-mail]
Name
E-mail Address
8480 HONEYCUTT RD STE 200
8480 HONEYCUTT RD STE 200
Current Mailing Address
Current Street Address
RALEIGH NC 27615-2261
RALEIGH NC 27615-2261
City
State
Zip
City
Telephone [phone] Fax Number NIA
State
Zip

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
Disturbance Permit:
matter relating to the Wake County Erosion and Sedimentation Gontrol Ordinance and/or Land
Charles Hassinger
Name
8480 Honeycutt Rd., Suite 243
Current Mailing Address
[e-mail]
E-mail Address
8480 Honeycutt Rd., Suite 243
Current Street Address
Raleigh NC 27615 Raleigh NC 27615
city State zip city State
Zip
Telephone [phone] Fax Number 855-873-1921
(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:
Kenyon Burnham _
Name of Registered Agent ..
1080 Pittsford Victor Road
Uunrent Mailing Address
kbumha2 u.rochester.edu
E-mail Address
1080 Pittsford Victor Road
Current Street Address
Pittsford NY 14534 Pittsford NY 14534
City State zip City State Zip
Telephone [phone] Fax Number N/A
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.
Kenyon Burnham Vice -President
Type or print name Title or Authority
ii�g�nao�/l z /ture pate
a Notary Public of the County of
State of North Carolina, hereby certify that en u ph on, k appeared
personally before me this day and being duly sworn acknowle ged that the above form was executed by him.
Witness my hand and notarial seal, this 19 day of hopwS__,� 20�_
"%t a Pik 'I",
Seal = • �GTARy
Notary
. C.E1 L.J
= = My commission expires
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