NCC233408_FRO Submitted_20231128

11:WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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
NORTH CAROLINA 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 Wendell Falls- Lot 27B Restaurant
2. Location of land-disturbing activity: Jurisdiction Wendell (Wake Co. or Municipality)
Highway/Street Treelight Way Latitude 35° 46' 27" N Longitude 78°25' 58"W
3. Approximate date land-disturbing activity will commence:
Fall 2023
4. Type of development(residential, commercial, industrial, institutional, etc.):
Restaurant
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):2.28
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
George Barnes
E-mail Address [e-mail]
Telephone[phone] Cell # Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Nash Wendell Falls 919-815-7458 tanya.matzen@brool
Name(s) Telephone Fax or E-mail address
4020 Westchase Blvd, Suite 150 Same as Mailing Address
Current Mailing Address Current Street Address
Raleigh NC 27606
City State Zip City State Zip
8. Deed Book No. 19076 Page No.00735 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):
TNV Capital, LLC [e-mail]
Name E-mail Address
3825 Barrett Drive Same as Mailing Address
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
Telephone[phone] Fax Number

1
I
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
George Barnes Manager
Type or rint name Title or Authority
�d-�-- 6/28/2023
Signat a Date
I. Tiffani Bylow , a Notary Public of the County of Wake
State of North Carolina, hereby certify that George T. Barnes 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 28th day of June , 20 23
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Nota 8/
Seal
Notary Public My commission expires 5-04-2028
Woke County
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