NCC223188_FRO Submitted_20220920

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
Comments
PROJECT Tracking
number
Bartlett Job No. 21-760
Complete
Application/NOI
Application Received date
SIC Code (Primary)
1522
Commercial (30001) = 1542, Highway (30005) = 1611, Industrial (30002)
= 1541, Residential, Single Family Houses (SFE) = 1521, Residential,
other than SFE (30000) = 1522, others = blank
Project or Site name
Moss Street Townhomes
Site Street Address
Southeast corner of Moss Street & Kenan Street
Site City
Wilson
Site County
Wilson
Site State
NC
Site Zip Code
27893
Site/Facility Type of
Ownership
POF
Non -Government = POF (default)
Government - County = CNG
Government - Federal = FDF
Government - Municipal = MWD
Organization Government - State = STF
Approximate Activity
Start Date
Summer 2022
Total Acres of
Distrubance
s, v.
j 9
FRO - First Name
Dewayne
**MUST be Financially Responsible Owner Person"
FRO -Last Name
Washington
**MUST be Financially Responsible Owner Person**
FRO - Organization
Formal Name
Moss Street Development, LLC
"MUST belong to Financially Responsible Owner**
FRO - eMail Address
[e-mail]
"MUST belong to Financially Responsible Owner"
FRO - Mailing Street
Address
P.O. Box 650
"MUST belong to Financially Responsible Owner"
FRO - Mailing
Supplemental Location
Text
N/A
"MUST belong to Financially Responsible Owner"
FRO - Mailing City
Durham
"MUST belong to Financially Responsible Owner"
FRO - Mailing State
NC
"MUST belong to Financially Responsible Owner"
FRO - Mailing Zip Code
27702
**MUST belong to Financially Responsible Owner"
Latitude: Decimal
Degrees
35.726
Longitude: Decimal
Degrees
-77.915

Sv Adz-
(#) ACRES TO BE DISTURBED X $150.00 /ACRE= 219.00 I q,,�5'Q`Oo���
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:
Dewayne Washington
Financially Responsible Person
or
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.)
6/22/22 .
Date
Manager
Title or Authority
Signature
Dewayne Washington
Type or Print Name
lJa—) 3'ronoE a Notary Public of the Countyof DttkA6 M State of North Carolina
hereby certifies
personally appeared before me this day and under oath acknowledged that the
above form was executed by him.
�� hhno rr L �
Witness my hand and notary seal, this cam' day of
(Notary Public
My commission expires G