NCC233216_FRO Submitted_20231027

R'.
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: The Carolinian
PROJECT LOCATION: Airport Blvd, Wilson, NC 27896
APPROXIMATE PROJECT START DATE: 10/1/2023
(#)ACRES TO BE DISTURBED 22.6 X$150.00/ACRE= $3,390
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.)
Heritage Crossing Holdings LLC
Name(Person or firm)
639 Executive Place, Suite 400
Street Address(No P.O.BOX)
Fayetteville, NC 28305
City,State,Zip
919-481-0501
Telephone It
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
Watson Caviness
Name(Person or Firm)
639 Executive Place, Suite 400
Street Address(No P.O.Box)
Fayettevllle, NC 28305
City,State,Zip
919-481-0501
Telephone#
Fax#
[e-mail]
E-mail address
PROJECT NAME: The Carolinian

WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Watson Caviness 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.)
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Title or hority
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Type or Print Name
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Title Da e
MA'C��K �l . f•rL /Q Y-4 ,a Notary Public of the County of £mlJ er/cz, ,
State of North Carolina hereby certifies
1 2 7&//V (4a v,/?e55 personally appeared before me this day and under
oath acknowledged that the above form was executed by him. �I
Witness my hand and notary seal,this c4 day of DcVeier ,4o07,3 .
(Notary Pub'
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c'My commission expires lJ(.1/h° � r OQ-, 1, •• isi
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