NCC232145_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 [e-mail] **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,-
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My commission expires ^-3 z�Z.Q t54' ? '
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