NCC221818_FRO Submitted_20220601

04 UE City of Henderson For City Use Only
e Received:
Engineering Department FroDatm:
Post Office Box 1434. 900 S. Beckford Dr.
Henderson, NC 27536-1434
Phone: [phone] / Fax: [phone]
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity covered by the Act before this form has been
completed and filed with the appropriate Office of the City of Henderson, Engineering Department,
Attn: Clark Thomas, Director of Engineering. Please make payable the appropriate fee that must
accompany submission of this form to "City of Henderson."
Part A
1. Name of Project:
2
Petco
Location of land disturbing activity: Latitude: 78.444167 —
(Highway/Street/Address) 160 US HWY 158 Bypass
3. Approximate date land disturbing activity will commence
4. Purpose of activity (residential, commercial, industrial, etc.):
5. Amount of acreage of land to be disturbed or uncovered:
Longitude: h6.437222 I
04.18.22
Commercial
�9,529 SF I Ac. .28�
Plan Review Fee* $ 1 woo
Permit Inspection Fee $ 225.00
0.50 acre to 0.999 acre = $75.00
0.50 acre to 0.999 acre = $125.00
1 to 3 acres = $100.00
1 to 3 acres = $225.00
More than 3 acres = $125.00 + 20.00 per acre
More than 3 acres = $325.00 + 20.00 per acre
6. Amount of fee enclosed (plan review + permit inspection): $ $325.00
7. Has an Erosion & Sedimentation Control plan been filed? Yes (0) No (FI) Enclosed (W)
8. Person to contact or send copy of inspection reports during construction who is responsible for
implementation of measures:
9
Contact Name: Gabriel Martinez
Email: [e-mail]
Phone No.: 512.819.4767
Cell No.: 512.677.3608
Land Uwner(s) of Kecord
use b1anK page to list additional owners
Owner 1
Owner 2
Name
PC -Henderson, NC-1-UT, LLC
Current Mailing Address
4747 Williams Drive
C4y?State/Zip Code
Georgetown, TX 78633
Telephone No.
512.819.4767
Email Address
[e-mail]
10. Indicate County, Book, and Page where deed or instrument is filed and attach a copy of the deed to this
form (use blank page to list additional deeds or instruments):
County Vance
County _
F". =9
Page 86
Rev. 08118

*The application fee for a single family residence with a lot I acre or more disturbed is $100.00
Part B
Person(s) or Firm(s) financially responsible for this land -disturbing activity:
Person/Firm
Person/Firm
Name
PC -Henderson, NC-1-UT, LLC
Current Mailing Address
4747 Williams Drive
CitylStatelZip Code
Georgetown, TX 78633
Telephone No.
512.819.4767
Email Address
[e-mail]
2. Reaistered Aaent, if anv. for the person or firm financially responsible:
3
Name
Cogency Global, Inc.
Current Mailing Address
212 South Tryon Street, Suite 1000
CVStatelZi Code
Charlotte, NC 28281 -0001
Telephone No.
866.775.0114
Email Address
[e-mail]
The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual and by
an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible per
Signature
Printed Name
Title or Authority
Date
I 'We-'5,z 'T A,404*1115 a Notary Public of the County of VJ4,ttt*,w,ov1 State of North Carolina,
1 —1
hereby certify that 6abtted tea-✓-hvv_2 personally
acknowledge that the above form was executed by him.
Witness my hand and notarial seal, this 2 day of Via-r-A
a�z'
Notary: 2I I M-0-M
' Y TERESA T. ADAMS
ti 0
i�'*!�g�i-6�' Notary Public, State of Texas
Comm. Expires 08-30-2025
Notary ID 12541661-9
before me this day and under oath
, 20 Z-7- .

E City of Henderson For City Use Only
Date Received:
Engineering Department From:
Post Office Box 1434. 900 S. Beckford Dr. Fee Enclosed:
CARDHenderson, NC 27536-1434
Phone: [phone] / Fax: [phone]
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
STORMWATER PROGRAM
(Applicable ONLY to developments within the City Limits of Henderson)
No person may initiate any development activity covered by the City's Stormwater Ordinance before
this form has been completed and filed with the appropriate Office of the City of Henderson,
Engineering Department, Attn.: Clark L. Thomas, City Engineer.
A stormwater management review fee of $400 is applicable and must be filed with this form.
Part A
1. Name of Project: Petco
2. Location of land disturbing activity: Latitude: 78.444167 Longitude: 36.437222
(Highway/Street/Address) 160 US HWY 158 Bypass
3. Has Site Plan been submitted? Yes (W) No
4. Purpose of activity (residential, commercial, industrial, etc.): Commercial
5. Amount impervious surface proposed:
Ac. or 56,306 Sf.
6. Has an Erosion & Sedimentation Control plan been filed? Yes (R) No (PP)
7. Person to contact or send copy of inspection reports during construction who is responsible for
implementation of measures:
D.,
U.
Contact Name: Gabriel Martinez
Address: 4747 Williams Drive
City/State/Zip Code: Georgetown, TX 78633
Phone No.: 512.819.4767
Cell No.: 512.677.3608
Email: [e-mail]
Land Owner(s) of Record
use blank page to list additional owners
Owner 1
Owner 2
Name
PC -Henderson, NC-1-LIT, LLC
Current Mailing Address
4747 Williams Drive
Ck)�/ tatelZip Code
Georgetown, TX 78633
Telephone No.
512.819.4767
Email Address
gmartinez@)embreegroup.com
Indicate County, Book, and Page where deed or instrument is filed and attach a copy of the deed with
any restrictive covenants to this form (use blank page to list additional deeds or instruments):
County Vance
County
Page 86
ZFM

Person(s) or Firm(s) financially responsible for this land -disturbing activity:
Person/Firm
Person/Firm
Name
PC -Henderson, NC-1-UT, LLC
Current Mailing Address
4747 Williams Drive
City/State/ZipCitylState/Zip Code
Georgetown, TX 78663
Telephone No.
512.819.4767
Email Address
[e-mail]
2. Registered Agent, if anv, for the person or firm financially responsible:
Name
Cogency Global, Inc.
Current Mailing Address
212 South Tryon Street, Suite 1000
Cit 1StatelZi Code
Charlotte, NC 28281-0001
Telephone No.
866.775.0114
Email Address
[e-mail]
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual and by
an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible person if not an individual). A
Signature
Printed Name
Title or Authority
Project Man
Date 03.23.2022
VEXA5
1, "Wl Oc, T Ada ctit 5 , a Notary Public of the County of Will iaAVsan , State off el+ea,
hereby certify that 6,A166 0 Hav�tvtGZ personally before me this day and under oath
acknowledge that the above form was executed by him.
Witness my hand and notarial seal, this 23''� day of Xape,G , 20 2Z
Notary:
TERESA T. ADAMS
Notary Public, State of Texa
Comm. Expires 08-30-2025
Notary ID 12541661-9