NCC220486_FRO Submitted_20220125

N©#TH CA1011NA
Financial Responsibility -Ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson Sedimentation and Erosion Control
Ordinance before completing and filing this form with the City of Wilson Erosion Control Division. (*Indicate N/A if a question is not
applicable)
Field Name Description
PROJECT Tracking
number
Complete Application Received date
Application/NOI
SIC Code (Primary)
Project or Site name
Site Street Address
Site City
Site County
Site State
Site Zip Code
Site/Facility Type of
Ownership
Approximate Activity
Start Date
Total Acres of
Distrubance
FRO - First Name
FRO -Last Namc
FRO - Organization
Formal Name
FRO - eMail Address
FRO - Mailing Street
Address
FRO - Mailing
Supplemental Location
Text
FRO - Mailing City
FRO - Mailing State
FRO - Mailing Zip Code
Latitude: Decimal
Longitude: Decimal
1541
Construct, Inc.
1610 Cargill Ave. S.
Wilson
Wilson
NC
27895
POF
Winter 2021
8.7
John
Barbee
Construct, Inc.
[e-mail]
1610 Cargill Ave. S.
N/A
Wilson
NC
27895
35.702
-77.907
Comments
Bartlett Job No. 21-378
Commercial (30001) = 1542, Highway (30005) = 1611, Industrial (30002)
= 1541, Residential, Single Family Houses (SFE) = 1521, Residential,
other than SFE (30000) = 1522, others = blank
Non -Government = POF (default)
Government - County = CNG
Government - Federal = FDF
Government - Municipal = MWD
Organization Government - State = STF
**MUST be Financiall,
Owner Person**
"MUST be Financially Responsible Owner Person**
**MUST belong to Financial
**MUST belong to Financial
**MUST belong to Financia
**MUST belong to Financially Res
**MUST belong to Financially Res
**MUST belong to Financially Res
**MUST belong to Financiallv Res
ponsible Owner**
ponsible Owner**
ponsible Owner**
ponsible Owner"
3onsible Owner**
)onsible Owner**
3onsible Owner**

(#) ACRES TO BE DISTURBED 8.7 X $150.00 /ACRE= $1,305.00
Person(s) or Firm(s) financially responsible for this land disturbing activity: (If out of state, a registered agent in North Carolina
must be used.)
In case of a violation please list the preferred contact (either the Financially Responsible Person or Registered Agent on the line
below:
John Barbee or
Financially Responsible Person
Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by me while under oath. (This
form must be signed by the Financially Responsible Person if an individual or by an officer, director, partner, and attorney -in -fact,
or other person with authority to execute instruments for the financially responsible person if not an individual.)
'IZ32
Date
Owner
Title or Author'
��z
Signature
John Barbee
Type or Print Nome
a Notary Public of the County ofG.SU: _ / State of North Carolina
hereby certifies
personally appeared before me this day and under oath acknowledged that the
above form was executed by him.
Witness my hand and notary seal, this .2 7 day of 1,0 f �02 .
t
(Notary Pu
My commission expires // /6
Steven Lee Oliverio
NOTARY PUBLIC
Wilson County, NC
My Commission Expires /1 1,f-4V3