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HomeMy WebLinkAboutNCC233769_FRO Submitted_20231222 • WILSON H (AY 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: TIDAL WAVE AUTO SPA WILSON PROJECT LOCATION:2901 RALEIGH ROAD PARKWAY APPROXIMATE PROJECT START DATE:10/15/2023 (#)ACRES TO BE DISTURBED 2.03 x$150.00/ACRE= $304.50 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.) SHJ DEVELOPMENT LLC Name(Person or Firm) 124 E Thompson St Street Address(No P.O.BOX) Thomaston, Georgia 30286 City,State,Zip 478-972-2418 Telephone# Fax/! martie@shjconstructiongroup.com E-mail address Registered agent for the person or firm who is financially responsible: CT Corperation System Name(Person or Firm) 160 Mine Lake CT, STE 200 Street Address(No P.O.BOX) Raleigh, North Carolina 27615 City,State,Zip 478-972-2418 Telephone# Fax/! martie@shjconstructiongroup.com E-mail address PROJECT NAME: TIDAL WAVE AUTO SPA WILSON WILSON In case of a violation please list the preferred contact(either the Financially Responsible Person or Registered Agent on the line below: MARTIE MURPHY 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.) 12/19/2023 Date DIRECTOR OF ENTITLEME Title or Auti7� 11 Signature MARTIE MURPHY Type or Print Name 21I °1 � 2,�23 Title Date 0242/1//,' a Notary Public of the County of 11/ State of hereby cerh'fies Lip personally appeared before me this day and under oath acknowledged that the above form was execc/u� by him. Witness my hand and otary seal,this / /wday of DC.e../44/LA.ri (Notary Public) +,,�Itlf'�. . My commission expires '��, + `(N C� Ey,p,RES GEORGIA ',.2Z ii,S:O N CO 0 04 "t f t VO