NCC223735_FRO Submitted_20221103

TOWN OF KNIGHTDALE FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Town
of Knightdale Unified Development Ordinance before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by Town of
Knightdale, Public Works Department, Stormwater Division. (Please type or print and, if the
question is not applicable, place N/A in the blank.)
Part A.
1. Project Name Stoneriver Phases 1 & 2
2. Location of land -disturbing activity: Town of Knightdale (Town Limits or ETJ)
Highway/Street Latitude Longitude
Hodge Rd/Panther Rock Blvd 35.76620-78.531739
3. Approximate date land -disturbing activity will commence: Fall 2019
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 52.43
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Ford E-mail Address [e-mail]
Phone # [phone] Cell # 336-707-0480
7 Landowner(s) of Record (attach accompanied page to list additional owners):
A.C. Knightdale Investments, LLC 305-972-5126 [e-mail]
Name(s) Telephone E-mail address
801 Brickell Avenue, Suite 2360 801 Brickell Avenue, Suite 2360
Current Mailing Address Current Street Address
Miami FL 33131 Miami FL 33131
City State Zip City State Zip
8. Deed Book No. 01 8283 Page No. 02180-02184 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):
A.C. Knightdale Investments, LLC bpearl [e-mail]
Name E-mail Address
801 Brickell Avenue, Suite 2360 801 Brickell Avenue, Suite 2360
Current Mailing Address Current Street Address
Miami FL 33131 Miami FL 33131
City State Zip City State Zip
Phone # [phone]

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 Town of Knightdale Erosion and Sedimentation Control Ordinance and/or
Land Disturbance Permit:
Gaines and Co. - George Grammer [e-mail]
Name
526 Three Sisters Road
Current Mailing Address
Knightdale NC 27�5
City State Zip
Phone # [phone]
E-mail Address
526 Three Sisters Road
Current Street Address
Knightdale NC 27545
City
State Zip
(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:
A.C. Knightdale Investments, LLC [e-mail]
Name of Registered Agent
801 Brickell Ave, Suite 2360
Current Mailing Address
Miami FL
E-mail Address
801 Brickell Ave, Suite 2360
Current Street Address
M131 Miami
FL 33131
City - State Zip City State Zip
Phone # [phone]
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.
Brian Pearl
Type 77_�//
't
Signature
Authorized Signatory
Title or Authority
10-21-22
Date
CAA II' Y 1I& , a Notary Public of the County of NQ PA i - c._-ade--
State of N�{vim hereby certify that (�1(lLl1'1 ��f�t` �- 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 0 f4(� , 20'2,?�-
it
Melissa Charrie
Notary Public A42
c State of Florida N&atvy
Seal ? Comm# HH002365 j � � i
�N �a►$ Expires 5/20/2024 My commission expires s 2 [N