NCC216565_FRO Submitted_20211130

For TOWF Uw Only
Pro];ect Name:
Date Received: _
Date, Approved:
L
Application 4--
Acres:
tees Paid:
V 6-
TOWN of
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 CONAPLETED AND APPROVED BY THE TOWN OF WAKE FOREST. MULTIPLE SINGLE
FAMILY LOTS THAT DISTURB MORE THAN %z ACRE ALSO REQUIRE A PERMIT AND SHALL FOLLOW THE STANDARD
PROCEDURES OUTLINED BELOW. SEE THE UN15iED DEVELOPMENT ORDINANCE FOR ADDITIONAL INFORMATION AND FULL
ORDINANCE REGULATIONS.
NorE: THE APPLICATION FEE OF $500.UU PER ACRE (ROUNDED LIP TO THE NEXT ACRE I. E.: I.I ACRES = 2 ACRES'
$500 - $I,000) IS DUE AT TIME OF SUBMITTAL. IF FEES ARE NOT SUAMITTED THE PLAN WILL AUTOMATICALLY BE
DISAPPROVED.
DISCG4IMER: TOWN OF WAKE FOREST FEES ANO CHARGES ARE SUBJECT TO CHANGE WITHOUT NOTICE.
PLEASE CALL 9I9-435,9443 TO CONFIRM CURRENT FEES AND CHARGES.
PART A: PROJECT INFORMATION
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PROJECT NAME4rt4aiz01�7
1 TAX PIN NUMBER k 13S I z4-22 13
2. ZONING h
3. LOCATION/ADDRESS OF TRACT GO L Cl. L�^ ---

4. SUBDIVISION yal LOT# �•••
S. DEED BOOK Do 7 PAGE
`PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
G. PURPOSE OF DEVELOPMENT j' U !m �u C-W>i v07 7
-� `+> '�T
7. TOTAL NUMBER OF UNITS
$. PERCENT IMPERVIOUS SURFACE Ip
9. TOTALTRACT ACREAGE: m -4
10. TOTAL ACREAGE Dim RBE0 (INCLUDING OFF -SITE UTILITIES AND ROADWORK):
11. AMDLJNT OF FEE ENCLOSED:
ROUNDED lip ACREAGE f _ ` $500/ACRE 000'
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 and charges.
12. PROPERTY OWNER(S) )PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET):
4*%A3 "C^t4Lr P►T 1
NAME LL4E-MA1L 11� � • GS��t
ADDRESS
PHONE
CELL 01 VJ, + •1n0571
13. PERSON TO CONS ACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND -DISTURBING ACTIVITY:
NAME E-MAIL • M her ���lniV� �"5� Co►+4
ADDRE55 _. ��yy�� ,,,,,, rr QQ -
PHONE CELL -y` p- 4��7�p

14. PLANS PREPARES] By Nv';�
s '
EMAIL "r�`C•, p�e,/ievS • �&AA--
PHONE Al L • S%, Je4S _ CELL iql ' SIS. (V~T
15. DocumENT5 SUWITTED (SUBMITTER TO PLACE A CHECK MARK IN THE Box):
FEES ($500 per acre rounded up, due upon 111 review)
FINANCIAL RESPONSIBILITY OWNER FORM
COMPLETED PLAN CHECKLIST
PLANS (to be submitted with construction set)
E&SC CALCULATIONS (1 copy)
STORMWATER CALCULATIONS (1 copy)
MAINTENANCE AND OPERATION AGREEMENT
NCDOT Encroachment/Driveway Permit
DWQ 401 Permit
USACOE 404 Permit
I NCG010000 Permit COC } ✓ i
EROSION & SEDIMENT CONTROL SURETY
APPROXIMATE DATE LAND -DISTURBING ACTIVITY WILL COMMENCE: A V Vt;r 0 2-1
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 LIDO.
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�iGNATURE TITLE DATE

PART B. FINANCIALLY RESPONSIBLE OWNER (FRO)/PERSONS INFORMATION
1. PERSON(S) OR FIRMS WH❑ ARE FINANCIALLY RESPONSIBLE FOR THE LAND -DISTURBING ACTIVITY (PROVIDE A
COMPREHENSIVE LIST OF ALLI RESPONSIBLE PART IE5 ON AN ATTACHED SHEET:
y l of Tr P20 olom r t� U co -ye (.0
NAME EMAI_
Ott 2-
ADDRESS
CITY STATE ZIP CODE
PHONE
9 111-
CELL
Z. If THE FINANCIALLY RESPONSIBLE PARTY IS NOT RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
NAME
ADDRESS
CITY
EMAIL
STATE ZIP CODE
PHONE CFII
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
ADDRESS
CITY STATE ZIP

PHONE
F► x
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.
iG
���)61
NAME %,
F
S1GNA'
-rd 1�a uaq e �
TITLE OR AUTHORITY
DAT
1, Rae- 0 , a Notary Public of the County of
'+' q aI r- , State of North Carolina, hereby certify that
r
t Qe i H J r ' 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 '!�;2-5-G(day of , 20cpj
Notary
My commission expires Q 1-o3-2��!