NCC232679_FRO Submitted_20230912

KIPP WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
„..--•••"1"111111111 SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAKECounty 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
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 Wallbrook-Townhomes
2. Location of land-disturbing activity: Jurisdiction Rolesville (Wake Co. or Municipality)
Highway/Street N. Main Street Latitude 35°54'48.70"N Longitude 78°28'19.60"
3. Approximate date land-disturbing activity will commence: October, 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): 1s.so
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Isaac, P.E. E-mail Address [e-mail]
Telephone [phone] Cell# 919-610-7875 Fax# N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Wallbrook Landco, LLC 704-621-6430 N/A
Name(s) Telephone Fax or E-mail address
3 Keel St, Suite 2 3 Keel St, Suite 2
Current Mailing Address Current Street Address
Wrightsville Beach NC 28480-1709 Wrightsville Beach NC 28480-1709
City State Zip City State Zip
8. Deed Book No.018103 Page No.01563 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):
Wallbrook Landco, LLC [e-mail]
Name E-mail Address
3 Keel St, Suite 2 3 Keel St, Suite 2
Current Mailing Address Current Street Address
Wrightsville Beach NC 28480-1709 Wrightsville Beach NC 28480-1709
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
Chris Taft [e-mail]
Name E-mail Address
2022 Progress Court, Suite 100-110 2022 Progress Court, Suite 100-110
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number N/A
(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:
J. Austin Williams [e-mail]
Name of Registered Agent E-mail Address
3 Keel St, Suite 2 3 Keel St, Suite 2
Current Mailing Address Current Street Address
Wrightsville Beach NC 28480-1709 Wrightsville Beach NC 28480-1709
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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.
J. Austin Williams Manager
Type or print ame ,� Title or Authority
6 7 '3 / z___a 2.—Z___
Signature Date
I, 4<a,(,.,' i-IC p7000 , a Notary Public of the County of T {'nc Vr—
State of No Carolina, hereby certify that James Austin Williams 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 J day of (.JLt It_ , 20 22
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'' 4.-r®1� Notary
Seal /* ®�` rZ
�rq ` ;Z? My commission expires
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III. GENERAL INFORMATION
1. Property Owner(s) (specify the name of the corporation,individual,etc.,who owns the property):
Name: Wallbrook Landco,LLC
Street Address: 3 Keel St,Suite 2 Wrightsville Beach,NC 28480-1709
Mailing Address: 3 Keel St,Suite 2 Wrightsville Beach,NC 28480-1709
E-Mail Address: [e-mail]
Phone#:( ) Cell#:(704 )621-6430 Fax#:(
2. Applicant*(Person to whom all correspondence will be sent):
Name: Todd°w
Firm/other: ".".^"
Street Address: '' P°,wT..a,"m,xrT"'
Mailing Address:
E-Mail Address: °°°^."@^^a°-^"°—
Phone#: [phone] Cell#: ( ) Fax#:_(
Relationship to Owner: Engineer
*If not a resident of North Carolina,a North Carolina agent must be designated for the purpose of receiving correspondences.
IV. APPLIICANT�'SS CERTIFICATION: /
PRINT NAME 1/• 6 G A•vi ej(/! /`(a 4.
SIGNATURE DATE (p-le
OWNER/PE SON FINANCIALLY RESPONSIBLE
V. Residential Construction Plan Review Fees:
S&E 14.50 x $250.00 = $4,625
Disturbed acres(to tenth of acre) round to nearest dollar
NO CAP/minimum fee based on 1 acre
*SW x $250.00 =
Disturbed acres(to tenth of acre) round to nearest dollar
(10-Acre Cap or minimum of$250.00)
*Minor Flood Study please add$500.00/each crossing x 500.00 =
*Major Flood Study please add$1,000.00/each crossing x 1,000.00 =
Total Fees Due $4,625
VI. Non-Residential Construction Plan Review Fees:
S&E x $250.00 =
Disturbed acres(to tenth of acre) round to nearest dollar
NO CAP/minimum fee based on 1 acre
$250(0-9 acres)
$375(10-19 acres)
*SW x $435(20-29 acres) =
Disturbed acres(to tenth of acre) $470(30-39 acres) round to nearest dollar
(50 Acre Cap) $485(40-50 acres)
*Minor Flood Study please add$500.00/each crossing x 500.00 =
*Major Flood Study please add$1,000.00/each crossing x 1,000.00 =
Total Fees Due
*Applies only to Wake County Jurisdictional Projects (form updated April 2019)
PERMIT FEES FOR STORMWATER AND EROSION CONTROL. DUE UPON PERMIT ISSUANCE