NCC231145_FRO Submitted_20230420

WILSON
Financial Responsibility-Ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson
Sedimentation and Erosion Control Ordinance before completing and filing this form with the City of
Wilson Erosion Control Division. (*Indicate N/A if a question is not applicable)
PROJECT NAME: WAWA - #5915 Raleigh Road Parkway W.
PROJECT LOCATION: 5003 Raleigh Road Parkway W. Wilson, NC 27896
APPROXIMATE PROJECT START DATE: 03/01/2022
(#)ACRES TO BE DISTURBED 2.16 ACX$150.00/ACRE= $324.00
Person(s)or Firm(s)financially responsible for this land disturbing activity:(If out of state,a registered
agent in North Carolina must be used.)
Woodhaven Development Group
Name(Person or Firm)
6000 Fairview Road. Suite 1530
Street Address(No P.O.BOX)
Charlotte, NC 28210
City,State,Zip
704-506-1502
Telephone#
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
Zack Kosofsky
Name(Person or Firm)
6000 Fairview Road. Suite 1530
Street Address(No P.O.BOX)
Charlotte, NC 28210
City,State,Zip
704-506-1502
Telephone#
Fax#
zack(a�woodhavendg.com
E-mail address
PROJECT NAME: WAWA - #5915 Raleigh Road Parkway W.

WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Zack Kosofsky or
Financially Responsible Person Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by
me while under oath. (This form must be signed by the Financially Responsible Person if an individual or
by an officer,director,partner,and attorney-in-fact,or other person with authority to execute
instruments for the financially responsible person if not an individual.)
12/21/22
Date
Managing Member
Title or Authori
Signature
ack Kosofsky
Type or Print Name
Managing Member 12/21/22
Title Date
\ I y� 1^ _ Y t//�
l� r I( q k S ,a Notary Public of the County of Y \O
State ofofn N th Carolina hereby certifies
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C K 1(US l 1 K�� personally appeared before me this day and under
oath acknowledged that the above form as executed by him.
Witness my hand and notary seal,this 721 S I day of De (-�m , 2.0 ZZ.
(Notary Public) U
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My commission expires 30—Z()Z3. ,'•
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