NCC230497_FRO Submitted_20230224

NORTH CAROLINA
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
Complete
Application/NOI
Application Received date
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
SIC Code (Primary)
30001
Projector Site name
SYNERGY II AUTO CARE
Site Street Address
3717 Nash Street NW
Site City
Wilson
Site County
Wilson
Site State
NC
Site Zip Code
27896
Site/Facility Type of
Ownership
POF
Approximate Activity
Start Date
FEBRUARY 6, 2023
Total Acres of
Disturbance
0.60 ACRES
FRO - First Name
Joshua
**MUST be Financially Responsible Owner Person**
FRO -Last Name
Dougherty
**MUST be Financially Responsible Owner Person**
FRO - Organization
Formal Name
Low Life Investments, LLC
**MUST belong to Financially Responsible Owner**
FRO - eMail Address
[e-mail]
**MUST belong to Financially Responsible Owner**
FRO - Mailing Street
Address
3721 Nash St. NW
**MUST belong to Financially Responsible Owner**
**MUST belong to Financially Responsible Owner**
FRO - Mailing
Supplemental Location
Text
FRO - Mailing City
Wilson
**MUST belong to Financially Responsible Owner**
FRO - Mailing State
NC
**MUST belong to Financially Responsible Owner**
FRO - Mailing Zip Code
27896
35.7688
**MUST belong to Financially Responsible Owner**
Latitude: Decimal
Degrees
Longitude: Decimal
Degrees
-77.9405

(#) ACRES TO BE DISTURBED 0.60 AC X $1S0.00 /ACRE= $180.00
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:
Low Life investments, LLC
Financially Responsible Person
Ronnie L. Sutton, PE
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.)
1 26 23
Date
Owner -Manager
Title or Authority
Type or Print Name
Owner -Manager
Title
Date
J
g&f_' (, iil'!ti'1 G a Notary Public of the Countyof A le. State of North Carolina
hereby certifies r
k■ personally appeared before me this day and under oath acknowledged that the
above form was executed ffy him.
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