NCC232659_FRO Submitted_20230922

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WILSON
A00„-,A
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: Richie's-Parking Addition
PROJECT LOCATION: 800 S. Lodge St. Wilson, NC
APPROXIMATE PROJECT START DATE:7-27'23
(#)ACRES TO BE DISTURBED 0.9 X$150.00/ACRE=$135.00
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.)
Sucilla Richardson
Name(Person or Firm)
3603 Millridge cir. W.
Street Address(No P.O.BOX)
Wilson, NC 27893
City,State,Zip
252-230-7533
Telephone#
N/A
Fax#
[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#
Fax#
E-mail address
PROJECT NAME: Richie's-Parking Addition

WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Sucilla Richardson (owner) 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— zy-23
Date
Owner �����a11ST91ur„
Title or hori 0\�� C'1-<70,s;
pTARy
Signature 3 Q \_` s
Sucilla Richardson =-
Type or Print Name P U B ..\G
Owner / V ,-y��hr arsaT
ti�
Title Date y4qC0UNN���
Jd.f i c! e W. ri e k(&ad ,a Notary Public of the County of Pf 'f*
State of North/ Carolina hereby certifies
Sc I/l(�- i?in/(ALLrd. Oh personally appeared before me this day and under
oath acknowledged that the above form was executed by him.
Witness my hand and notary seal,this cp
/( day of J U l y , a 043
(Notary Public) i?t/n.A 11.)
My commission expires 11J g(71 -aliv