NCC224215_FRO Submitted_20230110

For TOWF Use Only Application #:
Project Name:
Date Received: Acres:
Date Approved: Fees Paid:
TOWN of
WAKE FOREST
LAND DISTURBING (E&SC)
PERMIT APPLICATION, PLAN CHECKLIST, &
FINANCIALLY RESPONSIBLE OWNER (FRO) FORM
NO PERSON MAY INITIATE ANY LAND -DISTURBING ACTIVITY ON 1/2 ACRE OR MORE BEFORE THESE FORMS, FEES, AND AN
EROSION AND SEDIMENTATION CONTROL PLAN SEALED BY A NORTH CAROLINA REGISTERED PROFESSIONAL ENGINEER OR
LANDSCAPE ARCHITECT HAVE BEEN COMPLETED AND APPROVED BY THE TOWN OF WAKE FOREST. MULTIPLE SINGLE
FAMILY LOTS THAT DISTURB MORE THAN Y2 ACRE ALSO REQUIRE A PERMIT AND SHALL FOLLOW THE STANDARD
PROCEDURES OUTLINED BELOW. SEE THE UNIFIED DEVELOPMENT ORDINANCE FOR ADDITIONAL INFORMATION AND FULL
ORDINANCE REGULATIONS.
NOTE: THE APPLICATION FEE OF $500.00 PER ACRE ROUNDED UP TO THE NEXT ACRE I.E.: 1.1 ACRES = 2 ACRES*
$500 = $1,000) IS DUE AT TIME OF SUBMITTAL. IF FEES ARE NOT SUBMITTED THE PLAN WILL AUTOMATICALLY BE
DISAPPROVED.
DISCLAIMER: TOWN OF WAKE FOREST FEES AND CHARGES ARE SUBJECT TO CHANGE WITHOUT NOTICE.
PLEASE CALL 919-435-9443 TO CONFIRM CURRENT FEES AND CHARGES.
PART A: PROJECT INFORMATION
PROJECT NAME Pines at Wake Forest
1. TAX PIN NUMBER 1851044195
2. ZONING RMX
3. LOCATION/ADDRESS OF TRACT 704 Royal Mill Ave.

4. SUBDIVISION N/A
S. DEED BOOK 018736
PAGE 02695
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT Multi -family residential
7. TOTAL NUMBER OF UNITS 99
8. PERCENT IMPERVIOUS SURFACE 43%
9. TOTAL TRACT ACREAGE: 6.35 acres
LOT# N/A
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF -SITE UTILITIES AND ROADWORK): 5.06 AC
11. AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE 6
CHECK NUMBER
* $500/ACRE = $ 3,000
DATE PAID
DISCLAIMER: Town of Wake Forest fees and charges are subject to change without notice. Please call 919-435-
9443 to confirm current fees and charges.
12. PROPERTY OWNER(S) (PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET):
NAME PG Pines at Wake Forest LLC E-MAIL [e-mail]
ADDRESS 46 Prince St., Suite 2003, Rochester, NY 14607
PHONE 585.435,4766
CELL
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND -DISTURBING ACTIVITY:
NAME PG Pines at Wake Forest LLC E-MAIL [e-mail]
ADDRESS 46 Prince St., Suite 2003, Rochester, NY 14607
PHONE [phone] CELL

14. PLANS PR[PARCn BY Stewart, Inc
ADDRESS 223 S. West St., Sulle 1100, Re
EMAIL JpungQstewertlnc,Com
NC 27603
PHONE [phone] CELL
15. DOCUMENTS SUBMITTED (SUBMIT -TER TO PLACE A CHECK MARK IN THE BOX):
FEES ($500 per acre rounded up, due upon V review)
X
FINANCIAL RESPONSIBILITY OWNER FORM
X
COMPLETED PLAN CHECKLIST
X
PLANS (to be submitted with construction set)
E&SC CALCULATIONS (1 copy)
X
STORMWATER CALCULATIONS (1 copy)
X
MAINTENANCE AND OPERATION AGREEMENT
X
NCDOT Encroachment/Driveway Permit
NZA
DWQ 401 Permit
N/A
USACOE 404 Permit
N/A
NCGO10000 Permit COC
NIA
EROSION & SEDIMENT CONTROL SURETY
NIA
APPROXIMATE DATE LAND -DISTURBING ACTIVITY WILL COMMENCE: July 2022
THE SOIL EROSION AND SEDIMENTATION CONTROL PLAN, supporting documents, maps and
computations submitted for the above tract conform to the requirements of all applicable
sections of the Town of Wake Forest Erosion & Sedimentation Control Ordinance outlined in
the UDO.
9 Dirt cfiorLC-mI End . 02-/o�W %,I—
GNAtURE TITLE V DATE

PART B. FINANCIALLY RESPONSIBLE OWNER (FRO)/PERSONS INFORMATION
1. PERSON(S) OR FIRMS WHO ARE FINANCIALLY RESPONSIBLE FOR THE LAND -DISTURBING ACTIVITY PROVIDE A
COMPREHENSIVE LIST OF ALL RESPONSIBLE PARTIES ON AN ATTACHED SHEET:
PG Pines at Wake Forest LLC [e-mail]
NAME EMAIL
46 Prince St., Suite 2003
ADDRESS
Rochester NY 14607
CITY STATE ZIP CODE
585.435.4766
PHONE
CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
Weaver Cooke Construction, LLC [e-mail]
NAME
8401 Key Boulevard
ADDRESS
Greensboro NC
EMAIL
27409
CITY STATE ZIP CODE
336.378.7900
PHONE CELL
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:
Milton Kirkland
NAME OF REGISTERED AGENT E-MAIL ADDRESS
ADDRESS
VA
CITY STATE ZIP

334-�"lb-1Roo
PHONE
':�34— 3'Is—ZCke.�
FAX
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.
NAME
SIGNATURE
TITLE OR AUTHORITY
/12-e-112., Z-?
DAT
I, �f A4 a Notary Public of the County of
ga oiph , State of North Carolina, hereby certify that
H. P. gffl� appeared personally before me this day and being
duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this `S'll' day of J00 20�1-
W � 6M&km1
Notary
My commission expires (J
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