NCC215661_FRO Submitted_20211013

For TOWF Use Only Application tf:
Project Name:
Date Received: Acres:
Date Approved: Fees Paid:
TOWN of
WAKE FOREST
LAND DISTURBING (E&SC)
PERMIT APPLICATION, PLAN CHECKLIST, &
FINANCIALLY RESPONSIBLE OWNER (FRO) FORM
NO PERSON MAY INITIATE ANY LAND -DISTURBING ACTIVITY ON 1/2 ACRE OR MORE BEFORE THESE FORMS, FEES, AND AN
EROSION AND SEDIMENTATION CONTROL PLAN SEALED BY A NORTH CAROLINA REGISTERED PROFESSIONAL ENGINEER OR
LANDSCAPE ARCHITECT HAVE BEEN COMPLETED AND APPROVED BY THE TOWN OF WAKE FOREST. MULTIPLE SINGLE
FAMILY LOTS THAT DISTURB MORE THAN Y ACRE ALSO REQUIRE A PERMIT AND SHALL FOLLOW THE STANDARD
PROCEDURES OUTLINED BELOW. SEE THE UNIFIED DEVELOPMENT ORDINANCE FOR ADDITIONAL INFORMATION AND FULL
ORDINANCE REGULATIONS.
NOTE: THE APPLICATION FEE OF $500.00 PER ACRE (ROUNDED UP TO THE NEXTACRE 1.E.: 1.1 ACRES = 2 ACRES*
$500 = $1,000) 15 DUE AT TIME OF SUBMITTAL. IF FEES ARE NOT SUBMITTED THE PLAN WILL AUTOMATICALLY BE
DISAPPROVED.
DISCLAIMER: TOWN OF WAKE FOREST FEES AND CHARGES ARE SUBJECT TO CHANGE WITHOUT NOTICE.
PLEASE CALL 919-435-9443 TO CONFIRM CURRENT FEES AND CHARGES.
PARTA: PROJECT INFORMATION
PROJECT NAME Everly- Phase 4
1. TAx PIN NUMBER see attached
2. ZONING R-10
3. LOCATION/ADDRESS OF TRACT see attached

4. SUBDIVISION Everly LOT# see attached
5. DEED BOOK 2142
PAGE 971-977
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT Single Family Homes
7. TOTAL NUMBER OF UNITS 7 lots 1/lot
8. PERCENT IMPERVIOUS SURFACE
9, TOTAL TRACT ACREAGE: 1.190
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF -SITE UTILITIES AND ROADWORK): 1.190
11. AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE 2 * $500/ACRE = $ 1,000
CHECK NUMBER (A
DATE PAID i + `1- a
DISCLAIMER: Town of Wake Forest fees and charges are subject to change without notice. Please call 919-435-
9443 to confirm current fees and charges.
12. PROPERTY OWNER(S) (PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET : See attached for
add'I owner
NAME James E. Allen, LLC EMAIL [e-mail]
ADDRESS 5000 Falls of Neuse Road, Suite 100, Raleigh, NC 27609
PHONE [phone] CELL n/a
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND -DISTURBING ACTIVITY:
NAME Charles Adams
EMAIL [e-mail]
ADDRESS 933 Old Knight Road, Knightdale, NC 27545
PHONE [phone] CELL n/a

4. SuBDlvisio
LOT#
5. DEED BOOK PAGE
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT
%. TOTAL NUMBER OF UNITS
8. PERCENT IMPERVIOUS SURFACE
9. TOTAL TRACT ACREAGE:
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF -SITE UTILITIES AND ROADWORK):
11. AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE * $500/ACRE = $
CHECK NUMBER
DATE PAID
DISCLAIMER: Town of Wake Forest fees and charges are subject to change without notice. Please call 919-435-
9443 to confirm current fees a
PROPERTY OWNER(S) (PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET):
NAME Jordan's Construction, Inc. E-MAIL [e-mail]
ADDREss 8341 Bandford Way, Suite 101, Raleigh, NC
NQN_E919-110-0669 CELL NIA
13. PERSON TO CONTACT SH_0DtI5+RQSL0R AND SEDIMENT CONTROL ISSUES AR ND -DISTURBING ACTIVITY:
NAME
ADDRESS
E-MAIL
PHONE CELL

14. PLANS PREPARED BY Charles Tripp, Director of Construction
ADDRESS 933 Old Knight Road, Knightdale, NC 27545
EMAIL [e-mail]/ [e-mail]
PHONE [phone] CELL Nataleigh: 919-268-9127
15. DOCUMENTS SUBMITTED (SUBMITTER TO PLACE A CHECK MARK IN THE BOX):
FEES ($500 per acre rounded up, due upon 111 review)
X
FINANCIAL RESPONSIBILITY OWNER FORM
X
COMPLETED PLAN CHECKLIST
X
PLANS (to be submitted with construction set)
X
E&SC CALCULATIONS (1 copy)
X
STORMWATER CALCULATIONS (1 copy)
X
MAINTENANCE AND OPERATION AGREEMENT
X
NCDOT Encroachment/Driveway Permit
DWQ 401 Permit
USACOE 404 Permit
NCGO10000 Permit COC
EROSION & SEDIMENT CONTROL SURETY
APPROXIMATE DATE LAND -DISTURBING ACTIVITY WILL COMMENCE: 10-7-2021
THE SOIL EROSION AND SEDIMENTATION CONTROL PLAN, supporting documents, maps and
computations submitted for the above tract conform to the requirements of all applicable
sections of the Town of Wake Forest Erosion & Sedimentation Control Ordinance outlined in
the UDO.
Permits Coordinator 9--22-2021
SIGNATURE TITLE DATE

PART B. FINANCIALLY RESPONSIBLE OWNER (FRO)/PERSONS INFORMATION
1. PERSON(S) OR FIRMS WHO ARE FINANCIALLY RESPONSIBLE FOR THE LAND -DISTURBING ACTIVITY (PROVIDE A
COMPREHENSIVE LIST OF ALL RESPONSIBLE PARTIES ON AN ATTACHED SHEET):
Thomas Brian Herring, Managing Member [e-mail]
NAME Herring Realty LLC EMAIL
i ]Is]ro1F2 11 NNW. 4
ADDRESS
Knightdale, NC 27545
CITY STATE ZIP CODE
919-588-0552 919-650-8224
PHONE CELL
>F THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
TH DESIGNATED NORTH CAROLINA AGENT: n/a
N/A
NAME
ADDRESS
EMAIL
CITY STATE ZIP CODE
PHONE
CELL
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: n/a
N/A
NAME OF REGISTERED AGENT E-MAILADDRESS
ADDRESS
CITY STATE ZIP

PHONE
FAX
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.
-Sam5
-1:� r
r
TITLE OR AUTHO ITY
DATE
a Notary Public of the County of
Uhh5idV) , State of North Carolina, hereby certify that
-TIANS V-fA,(N Hqjri11'VW appeared personally before me this day and being
duly sworn acknowledged that thW above form was executed by him.
Witness my hand and notarial seal, this aka
My commission expires. 7 - a 1- aa--N
day of 20
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