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HomeMy WebLinkAboutNCC230525_FRO Submitted_20230224CW_ WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 0=7 SEDIMENTATION POLLUTION CONTROL ACT ��No person may initiate any land -disturbing activity on one or more acres as covered by the Wake County Unified Development Ordinance before this form and an acceptable erosion and COUNTY sedimentation control plan have been completed and approved by Wake County Department of NOR I'fI ('ARUI INA Environmental Services, Water Quality Division. (Please type or print and, if the question is not applicable, place NIA in the blank.) Part A. 1. Project Name Take 5 Car Wash 2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality) Highway/Street Fayetteville Rd. _ Latitude 35.722588 Longitude-78.653296 3. Approximate date land -disturbing activity will commence: 10f 112022 4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 1.04 acres 6. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Rebecca McAllister Telephone (281) 660-9580 Cell # E-mail Address rebecca.mcallister@drivenbrands.com Fax # 7. Landowner(s) of Record (attach accompanied page to list additional owners): Jing Hwa, Inc. - Derek Chan 917-841-8111 Name(s) Telephone 16137 91 st Street 16137 91 st Street Current Mailing Address Current Street Address Howard Beach, NY 11414 Howard Beach, NY 11414 City State Zip City State 8. Deed Book No. 017526 Part B. Page No. 00284 Fax or E-mail address Zip Provide a copy of the most current deed. 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): Boing US Holdco, Inc. (dba "Take 5 Car Wash") PropertyManagement@drivenbrands.com Name E-mail Address 440 South Church Street, Suite 700 440 South Church Street, Suite 700 Current Mailing Address Current Street Address Charlotte, NC 28202 City State Charlotte, NC 28202 Zip City Telephone 704-377-8855 Fax Number State Zip 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 Wake County Erosion and Sedimentation Control Ordinance and/or Land Disturbance Permit. Corporation Service Company Name of Registered Agent 2626 Glenwood Ave Ste 550 Current Mailing Address Raleigh, NC 27608 City Telephone E-mail Address Current Street Address State Zip City Fax Number 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: Corporation Service Company Name of Registered Agent 2626 Glenwood Ave Ste 550 Current Mailing Address Raleigh, NC 27608 City Telephone E-mail Address Current Street Address State Zip City Fax Number State Zip 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. Scott O'Melia Secretary Type or grin '' ame (,1 Title or Auth rity Signature Date I,&e-I-do ,I �ry" - A:L 1-15. , a Notary Public of the County of —An(,C' LL�'_j'1���C State of North Carolina, hereby certify that _aX c_' L\'�]� i 1 C\ 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 3 day of 20 BRENDA GALLMAN-AR71S Notary Public, North Carolina NOtg J Mec�ggpurg County y ` My Commission Expires October20,2024 My commission expires {Date) Re: Take 5 Car Wash — Redevelopment To whom it may concern: This letter provides permission to Boing US Holdco, Inc dba Take 5 Car Wash. to seek and obtain plan approval to perform grading and%r sitework associated with the above referenced project. By signing below the undersigned parties agree to the following: DESCRIPTION of location and purpose of work Parcel #1701-28-9110 located at 4202 Fayetteville Road, Raleigh, NC 27603 and being 0.962 +/- acres in size. The purpose of this work will be to facilitate the redevelopment with a single bay automated carwash and subsequ t parking loth 'th vacuum stalls. Signature of property owner or authorized representative ling Hwa, fnc. — Derek Chan Printed name of property owner, company group, corporation, or individual, and authorized representative. 16137 915L Street, Howard Beach, NY 11414 Mailing address of owner or party represented above a Notary Public of the County of State of hereby certify that LaLi � appeared personally before mty and being duly sworn acknowledged that the above form was executed by Kim. Witness my hand and notarial seal, this lDay of otary Seal My commission expires O a- '7 2 LESLIE TORRES Notary Public - State of New Yo; i, No. 01T06319258 Qualified in Nassau County My Commission Expires Feb. 17, 25_,Z3