NCC232188_FRO Submitted_20230721

WILSON
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)
PROJECT NAME: 1158 Place
PROJECT LOCATION: 2055 Airport Boulevard, Wilson, NC 27893
APPROXIMATE PROJECT START DATE: 7/2+1/23
(if)ACRES TO BE DISTURBED 5.67 x$150.00/ACRE= $900.00
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.)
Eastwood Home of Raleigh, LLC
Name(Person or Firm)
7101 Creedmoor Road, Suite 115
Street Address(No P.O.BOX)
Raleigh, North-Carolina, 27613
City,State,Zip
919-758-8208
Telephone#
Fax/i
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
Name(Person or Firm)
Street Address(No P.O.BOX)
City,State,Zip
Telephone ii
Fax#
E-mail address
PROJECT NAME: 1 158 Place

"SE
WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Andy CrAW.fo - ( 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.)
7//8/23
Date p
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Title or uthority
Signatur�
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Type or Print Name
Vice Pit.ride ,74- 7//8/23
Title Date
r' """, �f'� ,a Notary Public of the County of (.J01LQ
State
,�of�North
Carolina hereby certifies
at
tYNAA l Aiorc. personally appeared before me this day and under
oath acknowledged that the above form was executed by him.
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Witness my ha an n se ,t is ) day of c\LA\A c 3 .
(Notary Public)
My commission expiresCRkV 1e - j �•,`,psi FO4S%,,,,
Y NOTAR
PUBLIC
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