NCC232383_FRO Submitted_20230809

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: lglesia Pentecostes Camino De-Salvacion-Building Addition
PROJECT LOCATION:306 Spaulding St.Wilson, NC
APPROXIMATE PROJECT START DATE: Upon Approvals(July 15, 2023)
(#)ACRES TO BE DISTURBED 0.60 X$150.00/ACRE=$90.00
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.)
Iglesia Pentecostes Camino De-Salvacion (Angelico Guzman Maceda)
Name(Person or Firm)
306 Spaulding St.
Street Address(No P.O.BOX)
City,State,Zip
Wilson, NC
Telephone#
252-2818142
Fax#
'Angel Guzman' <[e-mail]>
E-mail address
Registered agent for the person or firm who is financially responsible:
Name(Person or Firm)
Street Address(No P.O.BOX)
City,State,Zip
Telephone#
Fax#
E-mail address
PROJECT NAME: lglesia Pentecostes Camino De-Salvacion-Building Addition

rs
WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Angelico Guzman Maceda 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.)
(16 122- J ,o; 3
Date
PAY
Title or Authority /1V
,,44
Signature
Angelico Guzman Maceda
Type or nt Name
05 NOV oG I 2923
Title Date
C\-�OJQ�1IX F 1 1.k\ c.L1\ ,a Notary Public of the County of \..A.) 1 v
State of North Carolina hereby certifies
r IICb t t'j W 4 J\ L C 2a Ck personally appeared before me this day and under
oath acknowledged that the above form was executed by him.
Witness my hand and notary seal,this a.a day of � ./1/4.1"_"e__ , �U
(Notary Public) 0).-A-....vcie.--\_ y___ ,),—
,,, F. pi
My co s io i 0 ...4
z My
it COMMISSION EXPIRES
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