NCC240280_FRO Submitted_20240214

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
i Development d be cab and
COUNTY sedimentationCountyUnif ed controlv plan haveOr beeninance completedefor and this approvedform byand an Wakeac Countyept le 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
Wendell
2. Location of land-disturbing activity: Jurisdiction (Wake Co. or Municipality)
Highway/Street Treelight Way Latitude 35° 46'26" N Longitude 78°25' 57"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) 1.35
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Andy Boothby 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@broil
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):
City Barbeque, LLC [e-mail]
Name E-mail Address
5168 Blazer Parkway Same as Mailing Address
Current Mailing Address Current Street Address
Dublin OH 43017
City State Zip City State Zip
Telephone[phone] Fax Number

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:
Greg Wittig,Agent for City BBQ, LLC [e-mail]
Name E-mail Address
2529 Grampian Lane Same as mailing address
Current Mailing Address Current Street Address
Fuquay-Varina NC 2b
City State Zip City State Zip
Telephone [phone] 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.
Andy Boothby Director of Construction
Type or print name Title or Authority
Olglinlly signed by Andy Boothby
Andy Booth by L ;cZo3oiiBoolhby34 ooaoB�mo=alrBBo. 7/11/2023
DalSignature Date
I. (}n\ �'I( 11J(,�Icy •l a Notary Public of the County of (��.1 1 n
State of �er+er hereby certify that PnCLA 600416appeared
personally before me this day and being duly sworn acknowledged that the above 4n was executed by him.
Witness my hand and notarial seal, this )I "day of .1}l)I . 20 23
..;Spa El,�q�� tart' -61g6/144-14.14.
/."--". JENNIFER E.GRYWP. My commission expires 09 /WO /w 0
NOTARY PUBLIC,STATE 0
FRANKLIN COUN
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