NCC221350_FRO Submitted_20220406

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
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
NORIH CAROHNA 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 Forestville Village
2. Location of land -disturbing activity: JurisdictionTown of Knightdale(Wake Co. or Municipality)
NWC Old Knight
Highway/Street & Forestville Latitude 35.806015 Longitude -78.476922
3. Approximate date land -disturbing activity will commence: April 2022
4. Type of development (residential, commercial, industrial, institutional, etc.)
Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 46.46 Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Rexroad
Telephone
E-mail Address drexroad@tollbrothers . com
Cell# 704-576-9620 Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
KL Toll Fort AIV, LLC
Name(s)
Ill W 33rd Street, Suite 1910
Current Mailing Address
919-321-4800
Telephone
[e-mail]
Fax or E-mail address
_111 W 33rd Street_, Suite 1910
Current Street Address
New York, NY 10001-2904 New York, NY 10001-2904
City State Zip City State Zip
D.B. 18849 PG. 2195
8. Deed Book No. D.B. 18857 Page No. PG. 695 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):
Toll Southeast LP Company, Inc.
Name
1140 Virginia Drive
Current Mailing Address
[e-mail]
E-mail Address
1140 Virginia Drive
Current Street Address
Fort Washington PA 19034 Fort Washington PA 19034
City State Zip City State Zip
Telephone [phone] 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:
David Rexroad
Name
900 Perimeter Part Dr, Suite B 3
Current Mailing Address
Morrisville NC 27560
City
State Zip
Telephone [phone]
[e-mail]
E-mail Address
900 Perimeter Part Dr, Suite B 3
Current Street Address
Morrisville NC 27560
City State Zip
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:
Name of Registered Agent
Current Mailing Address
City
Telephone.
State
E-mail Address
Current Street Address
Zip City State Zip
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.
Dan Rossi
Type or print name
Signature
Vice President
Title or Authority
Date
a Notary Public of the County of �21WriLA-
State of North Carolina, hereby certify that F)0-n E 10 �5I appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my ��ynd notarial seal, this A ► day of 20
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