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HomeMy WebLinkAboutNCC232145_FRO Submitted_20230718 WILSON ti O RIM l_4.4 i.:.:.d,. 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/N01 Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002) =1541,Residential,Single Family Houses(SFE)=1521,Residential, SIC Code(Primary) 1542 other than SFE(30000)=1522,others=blank Project or Site name Outback Steakhouse Site Street Address 3601 Raleigh Road Parkway W 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 August 1,2022 Total Acres of Distrubance 2.1 ACRES FRO-First Name Zack **MUST be Financially Responsible Owner Person** FRO-Last Name Kosofsky **MUST be Financially Responsible Owner Person** FRO- Organization Formal Name Woodhaven Wilson 2,LLC **MUST belong to Financially Responsible Owner** FRO-eMail Address zack@woodhavendg.com **MUST belong to Financially Responsible Owner** FRO-Mailing Street Address 8317 Six Forks Rd.,Suite 201 **MUST belong to Financially Responsible Owner** FRO-Mailing Supplemental Location Text **MUST belong to Financially Responsible Owner** FRO-Mailing City Raleigh **MUST belong to Financially Responsible Owner** FRO-Mailing State NC **MUST belong to Financially Responsible Owner** FRO-Mailing Zip Code 27615 **MUST belong to Financially Responsible Owner** Latitude:Decimal Degrees 35.745 Longitude:Decimal -77.966 Degrees • WILSON NORTH CAROLINA (#)ACRES TO BE DISTURBED 2.2 AC X$150.00/ACRE=$330.00 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.) In case of a violation please list the preferred contact(either the Financially Responsible Person or Registered Agent on the line below: Zack Kosofsky Ron Sutton 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.) 7-14-2023 Date Managing Mem er Title or Author"y Signs Zack Kosofsky, Woodhaven Wilson 2, LLC Type or Print Name Managing Member 7-14-2023 Title Date ko b e r-i-s' ,a Notary Public of the County of vV 0.Kt, ,State of North Carolina hereby certifies z a cK K O sO-fs �y personally appeared before me this day and under oath acknowledged that the above form was executed by him. Li Witness44- my hand and notary seal,this l l day of TU LI , 2c) 3. (Notary Public)9/47,- ,,,,,,,,, _0 •, Q __ fit'. My commission expires ^-3 z�Z.Q t54' ? ' • 711 efd • a,bl��