NCC240302_FRO Submitted_20240202

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)
Field Name Description Comments I
PROJECT Tracking
number
Complete
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 Willow Springs—Section VI—Lots 1-9
Intersection of Par Three Drive and Sunnybrook
Site Street Address Road
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 February 12,2024
Total Acres of
Disturbance 1.56 ACRES
FRO-First Name Luke **MUST be Financially Responsible Owner Person**
FRO-Last Name Fortner **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name Fortner Properties,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address [e-mail] **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 6069 Farmwood Loop **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text **MUST belong to Financially Responsible Owner**
FRO-Mailing City Wilson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27896 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
_ Degrees 35.6892
Longitude:Decimal
Degrees
-77.9444

WILSON
NO4TH C_A.. OIINA
(#)ACRES TO BE DISTURBED 1.37 AC X$150.00/ACRE=$205.50
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:
Luke Fortner,Owner Manager Fortner Properties,LLC Ronnie L.Sutton,PE
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.)
01/08/2024
Dote
Owner Manager
Title or Authority
?C- ''''' '''..... -70.----' ____.._---i
Signature .q1I I I I INI,.
Luke Fortner ,s,`Q-Y„•••, M p�99#
;*44/1 O TA q�"-- p
Type or Print Name ) it s`
Owner Manager /\ i f F / 2D7 4 z` '
Title Date ��;' A0B`-W '=``s`
Coli
if
rr ,,'rr ,rrfl,II it%,,'
/ e f e_Srk � PQ.r R_ ,a Notary Public of the County of hD L\1-(:I(\ ,State of North Carolina
hereby certifies
11- CI KC— I/`C)r"En C {- 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 IG day of city Calif U , •
(Notary Puffs!) •—ems I I 4)r,N,•�
My commission expires 1 I l 21;2-r7

WILSON
NORTH CARC
(#)ACRES TO BE DISTURBED 1.37 AC X$150.00/ACRE=$205.50
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:
Luke Fortner,Owner Manager Fortner Properties,LLC Ronnie L.Sutton, PE
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.)
01/08/2024
Date
Owner Manager
Title or Authority
Signature
Luke Fortner
Type or Print Name
Owner Manager
Title Date
,a Notary Public of the County of _,State of North Carolina
hereby certifies
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 day of ,
(Notary Public)______
My commission expires