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HomeMy WebLinkAboutNCC240020_FRO Submitted_20240104 WILSON NORTH CAROLINA 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) Field Name Description Comments PROJECT Tracking number Bartlett Job No.22-397 Complete Application Received date Application/N01 Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002) =1541,Residential,Single Family Houses(SFE)=1521,Residential, SIC Code(Primary) 1521 other than SFE(30000)=1522,others=blank Project or Site name 1158 Place Phase 3 Site Street Address Airport Blvd.W. Site City Wilson Site County Wilson Site State NC Site Zip Code 27896 Non-Government=POF(default) Government-County =CNG Government-Federal=FDF Site/Facility Type of Government-Municipal=MWD Ownership POF Organization Government-State=STF Approximate Activity Start Date Fall/Winter 2023 Total Acres of Distrubance 9.5 FRO- First Name Rex **MUST be Financially Responsible Owner Person** FRO-Last Name Vick Jr. **MUST be Financially Responsible Owner Person** FRO- Organization Formal Name RBV 1158,LLC **MUST belong to Financially Responsible Owner** FRO-eMail Address rvick@windjamdevelopment.com **MUST belong to Financially Responsible Owner** FRO-Mailing Street Address 3434-135 Kildaire Farm Road **MUST belong to Financially Responsible Owner** FRO-Mailing Supplemental Location Text N/A **MUST belong to Financially Responsible Owner** FRO-Mailing City Cary **MUST belong to Financially Responsible Owner** FRO-Mailing State NC **MUST belong to Financially Responsible Owner** FRO-Mailing Zip Code 27518 **MUST belong to Financially Responsible Owner** Latitude:Decimal Degrees 35.747 Longitude:Decimal Degrees -77.971 r WILSO (#)ACRES TO BE DISTURBED 9.5 X$150.00/ACRE=$1,425.00 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.) In case of a violation please list the preferred contact(either the Financially Responsible Person or Registered Agent on the line below: Rex Vick Jr. 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.) i 0 Date President A Title or Authority Signature Rex Vick Jr. Type or Print Name a Notary Public of the County of ( 5tate of North Carolina :y certifies 7 � V :personally appeared before me this day and under oath acknowledged that the above form was executed by him. 2�—y Witness my han nd nota "I,this day of •7 - (Notary P blic} My com is ' n expires CO MY XPIRES %y9), �'U LIG .,��r�14 ,M CO )t ' t sA