NCC231898_FRO Submitted_20230620

WILSON
NORTH CAROLINA
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)
Field Name Description Comments
PROJECT Tracking
number
Complete Application Received date
Application/N01
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 30000 other than SFE(30000)=1522,others=blank
Project or Site name Canterbury Village Duplexes Lots#3&#4
Site Street Address 2828-2830 Daisy Lane N.
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27896
Non-Government=POF(default)
Government-County =CNG
Government-Federal=FDF
Site/Facility Type of Government-Municipal=MWD
Ownership POF Organization Government-State=STF
Approximate Activity
Start Date June 26,2023
Total Acres of
Disturbance 1.69 ACRES
FRO-First Name TROY **MUST be Financially Responsible Owner Person**
FRO-Last Name ROUSE **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name Eastern Cabinet Properties,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address Troy Rouse<[e-mail]> **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 3100 Meteor Drive **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text **MUST belong to Financially Responsible Owner**
FRO-Mailing City Wilson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27893 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.7583
Longitude:Decimal
Degrees
-77.9301

W ILSON
NORTH CAROLINA
(#)ACRES TO BE DISTURBED 1.69 AC X$150.00/ACRE=$253.50
Person(s)or Firm(s)financially responsible for this land disturbing activity:(If out of state,a registered agent in North Carolina
must be used.)
In case of a violation please list the preferred contact(either the Financially Responsible Person or Registered Agent on the line
below:
TROY ROUSE-EASTERN CABINET PROPERTIES,LLC RON SUTTON,PE- HERRING-SUTTON AND ASSOCIATES,P.A.
Financially Responsible Person Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by me while under oath.(This
form must be signed by the Financially Responsible Person if an individual or by an officer,director,partner,and attorney-in-fact,
or other person with authority to execute instruments for the financially responsible person if not an individual.)
05/22/23
Date
Member/Manager
Title or Authority
X 2/ �. /1$ in1>R
Signature V
TROY ROUSE
Type or Print Name
MEMBER-MANAGER May 22,2023
Title Date
Ohe f e . MC").hb ,a Notary Public of the County of NCS A ,State of North Carolina
herebyy ]certifies
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"f C) t*SC personally appeared before me this day and under oath acknowledged that the
above form was executed by him.
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Witness my hand and notaryar- seal,this S day o�,��`tt
R � / , ZO Z�
(Notary Public) - �\Q0 T A� 161
My commission expires g f Z d O 2O ZV . A(, \C
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