NCC232166_FRO Submitted_20230720

For TOWF Use Only Application Si:
Project Name:
Date Received: Acres:
Date Approved: Fees Paid:
TOWN of
• _ •:�.. _ -- WAKE FOREST
LAND DISTURBING (E&SC)
PERMIT APPLICATION, PLAN CHECKLIST,&
FINANCIALLY RESPONSIBLE OWNER (FRO) FORM
NO PERSON MAY INITIATE ANY LAND-DISTURBING ACTIVITY ON 1/2 ACRE OR MORE BEFORE THESE FORMS,FEES,AND AN
EROSION AND SEDIMENTATION CONTROL PLAN SEALED BY A NORTH CAROLINA REGISTERED PROFESSIONAL ENGINEER OR
LANDSCAPE ARCHITECT HAVE BEEN COMPLETED AND APPROVED BY THE TOWN OF WAKE FOREST. MULTIPLE SINGLE
FAMILY LOTS THAT DISTURB MORE THAN % ACRE ALSO REQUIRE A PERMIT AND SHALL FOLLOW THE STANDARD
PROCEDURES OUTLINED BELOW.SEE THE UNIFIED DEVELOPMENT ORDINANCE FOR ADDITIONAL INFORMATION AND FULL
ORDINANCE REGULATIONS.
NOTE:THE APPLICATION FEE OF$500.00 PER ACRE(ROUNDED UP TO THE NEXT ACRE I.E.:1.1 ACRES = 2 ACRES*
$500=$1,000)IS DUE AT TIME OF SUBMITTAL.IF FEES ARE NOT SUBMITTED THE PLAN WILL AUTOMATICALLY BE
DISAPPROVED.
DISCLAIMER:TOWN OF WAKE FOREST FEES AND CHARGES ARE SUBJECT TO CHANGE WITHOUT NOTICE.
PLEASE CALL 919-435-9443 TO CONFIRM CURRENT FEES AND CHARGES.
PART A: PROJECT INFORMATION
PROJECT NAME ReFuel Market - Holding Village
1. TAX PIN NUMBER 1840965430
2. ZONING NMX, Neighborhood Mixed-Use District
3. LOCATION/ADDRESS OF TRACT Northeast corner of parcel
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4. SUBDIVISION Holding Village Loi# 10
5. DEED BOOK BM2021 PAGE 02339
please provide a copy
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED of the deed
6. PURPOSE OF DEVELOPMENT One convenience store with gasoline sales
and car wash
7. TOTAL NUMBER OF UNITS NA
8. PERCENT IMPERVIOUS SURFACE 5996
9. TOTAL TRACT ACREAGE: 1.89 a c
10.TOTAL ACREAGE DISTURBED(INCLUDING OFF-SITE UTILITIES AND ROADWORK): 1.7 ac
11.AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE 2.0 ac *$500/ACRE = $ $1000.00
CHECK NUMBER 124066
DATE PAID 07/11/2022
DISCLAIMER:Town of Wake Forest fees and charges are subject to change without notice.Please call 919-435-
9443 to confirm current fees and charges.
12.PROPERTY OWNER(S)(PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET):
NAME RP HV Lakeside, LLC E-MAIL [e-mail]
ADDRESS c/o Reader & Partners, LLC, 5850 T.G. Lee Blvd., Suite 200
Orlando, FL 32822
PHONE [phone] CELL 919.706.9397
13.PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND-DISTURBING ACTIVITY:
NAME Ryan Robinson E-MAIL [e-mail]
ADDRESS 547 Long Point Rd, Suite 103, Mt. Pleasant, SC 29464
PHONE CELL (865) 337-9372
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14.PLANS PREPARED BY McAdams
ADDRESS 621 Hillsborough St., Ste. 500, Raleigh, NC 27603
EMAIL [e-mail]
PHONE [phone] CELL
15.DOCUMENTS SUBMITTED(SUBMITTER TO PLACE A CHECK MARK IN THE BOX):
FEES($500 per acre rounded up,due upon 1st review) X
FINANCIAL RESPONSIBILITY OWNER FORM X
COMPLETED PLAN CHECKLIST X
PLANS(to be submitted with construction set) X
E&SC CALCULATIONS(1 copy) x
STORMWATER CALCULATIONS(1 copy) X
MAINTENANCE AND OPERATION AGREEMENT x
NCDOT Encroachment/Driveway Permit NA
DWQ401 Permit NA
USACOE 404 Permit NA
NCG010000 Permit COC
EROSION&SEDIMENT CONTROL SURETY
APPROXIMATE DATE LAND-DISTURBING ACTIVITY WILL COMMENCE: 05/01/2 02 3
THE SOIL EROSION AND SEDIMENTATION CONTROL PLAN,supporting documents,maps and
computations submitted for the above tract conform to the requirements of all applicable
sections of the Town of Wake Forest Erosion&Sedimentation Control Ordinance outlined in
the UDO.
Cwc� - 1,1 cei 3 • ao. a 3
SIGNATURE TITLE DATE
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PART B.FINANCIALLY RESPONSIBLE OWNER(FRO)/PERSONS INFORMATION
1. PERSON(S)OR FIRMS WHO ARE FINANCIALLY RESPONSIBLE FOR THE LAND-DISTURBING ACTIVITY(PROVIDE A
COMPREHENSIVE LIST OF ALL RESPONSIBLE PARTIES ON AN ATTACHED SHEET):
Refuel Operating Company, LLC [e-mail]
NAME EMAIL
547 Long Point Rd, Suite 103
ADDRESS
Mt. Pleasant, SC 29464
CITY STATE ZIP CODE
(865) 337-9372
PHONE CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA,GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
Corporation Service Company
NAME EMAIL
2626 Glenwood Avenue, Ste. 550
ADDRESS
Raleigh NC 27608
CITY STATE ZIP CODE
PHONE CELL
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 E-MAIL ADDRESS
2626 Glenwood Avenue, Ste. 550
ADDRESS
Raleigh NC 27608
CITY STATE ZIP
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PHONE FAX
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.
Travis Smith C�1re Drut(y,w.,1- D
NAME TITLE OR AUTHORITY
3•..7o•a3
SIGNATURE DATE
I, ELJZ4- ET1-1 p JI<riz4 ,a Notary Public of the County of
CH, TTa�l �vrN
State off Carolina,hereby certify that
7 ✓/S chi q 4, CPO 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 Z4 day of /t?klG)4 ,20 Z3
oa
ELIZABETH PLASTERS
Notary Public-State of South Caroline
My Commission Expires
My commission expires //o January 10,2032
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