NCC220640_FRO Submitted_20220204

For TOWF Use Only Application #: 262-1 —) 3361
Project Name: "AkA 71-A• t10CUr',y (QwA_CAJ-_',
Date Received: '51 'Zu 2 1 Acres: 3.00
Date Approved: IS lea I Z, Fees Paid: 41 15U0
WAKE
FOREST
�r
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 Y2 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 NEXT ACRE 1. E.: 1.1 ACRES = 2 ACRES*
$500 = $1,000) IS 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.
PART A: PROJECT INFORMATION
PROJECT NAME Wake Forest Holdings LLC - Tract 3
1. TAx PIN NUMBER_1830763187
2. ZONING _ _ _ _ RD
3. LOCATION/ADDRESS OF TRACT 0 Capital Blvd _

4. SUBDIVISION LOT#
5. DEED BOOK_017125 PAGE 01536
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT
7. TOTAL NUMBER OF UNITS TBD
8. PERCENT IMPERVIOUS SURFACE
9. TOTAL TRACT ACREAGE: 2.6 acres currrently (3.0 acres after land swap)
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF -SITE UTILITIES AND ROADWORK):
11. AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE 3.0
CHECK NUMBER
* $500/ACRE = $_1,500.00
DATE PAID
DISCLAIMER: Town of Wake Forest fees and charges are subject to change without notice. Please call919-435-
9443 to confirm current fees and charges.
12. PROPERTY OWNER(S) (PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET):
NAME James Duncan [e-mail]
ADDRESS 12229 Dunard St. Raleigh NC 27614
PHONE CELL 919-426-1526
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND -DISTURBING ACTIVITY:
NAME James Duncan [e-mail]
ADDRESS 12229 Dunard St. Raleigh NC 27614
PHONE CELL 919-426-1526

14. PLANS PREPARED By
ADDRESS
EMAIL
PHONE
CELL
15. DOCUMENTS SUBMITTED (SUBMITTER TO PLACE A CHECK MARK IN THE BOX):
FEES ($500 per acre rounded up, due upon 1st 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
NCG010000 Permit COC
EROSION & SEDIMENT CONTROL SURETY
APPROXIMATE DATE LAND -DISTURBING ACTIVITY WILL COMMENCE:
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.
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):
_Wake Forest Holdings LLC _ [e-mail]
NAME EMAIL
_12229 Dunard St.
ADDRESS
_Raleigh NC 27614_
CITY STATE ZIP CODE
919-426-1526
PHONE CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT'
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:
NAME OF REGISTERED AGENT E-MAIL ADDRESS
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.
_James Dunca
NAME
RE
Member
TITLE OR AUTHORITY
s�t-\i U2�
DATE
I, .4:!-:s , a Notary Public of the County of
, State of North Carolina, hereby certify that
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 day of _ r—T� 2024
Notary
My commission expir22 2�'
Ann S Lawson
NOTARY PUBLIC
Vance County, NC
MY Commission Expires February 22, 2026