NCC240952_FRO Submitted_20240402

For TOWF Use Only Application #:
Project Name:
Date Received: — Acres:
Date Approved: Fees Paid:
TOWN of
_ .• . •
, 4 - 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 %z 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 (4 dcH1TNo2 Pr ri4-m- t-ta2-e.ST {�t+a5ts
1. TAX PIN NUMBER I'I { " ( " Z1o23
2. ZONING le-- l6 GD") ( 1zI.. '
3. LOCATION/ADDRESS OF TRACT l lAce iz000 W Ac1GJe j2.IE%r-5 (VG Z753

4. SUBDIVISION ?_i 2•52'1 Pen c141 LOT# At-la
5. DEED BOOK ZD 23 PAGE -{ 48
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT iA 1M,tt.)-(
7. TOTAL NUMBER OF UNITS ./ ` )
8. PERCENT IMPERVIOUS SURFACE 3 o . /v
9. TOTAL TRACT ACREAGE: ' 5 "' ��-
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF-SITE UTILITIES AND ROADWORK): 3. 6 "
11. AMOUNT OF FEE ENCLOSED:
4f
ROUNDED UP ACREAGE * $500/ACRE _ $ �+'®
CHECK NUMBER_
DATE PAID
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):
aw-114.04t.oe AiT Wth1GEFIkZx:.
NAME TV.( 'r'S P4 rSt 1 LLC..E-MAIL
ADDRESS V®CO Cin ittrer4 Vit'etwke4Q, tsm k CYLIANSI3ato NC..
214o8- 707(O
PHONE CELL
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND-DISTURBING ACTIVITY:
NAME E-MAIL?Y"r\12ACiIG POWZ (�Gls ► Ci . p@re.Z ® ma-voiVe G.aS•«N
ADDRESS ttn• TWl)dp ®. W,V 1.NefrO N `1 Z8403
PHONE _ 1`g. % 5• (:)12.41". CELL

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):
V® ...Ate 64 N`$112 VCriON �. �¢r'e, Vo IV�e S -ccryviNAME raL4Y\
AIL
2012. on
ADDRESS
W«OA%WiTo wG 284 o?,
CITY STATE ZIP CODE
10• Z CI 42.0 t . S I5 . (07 24
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:
NAME EMAIL
ADDRESS
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:
NAME OF REGISTERED AGENT E-MAIL ADDRESS
ADDRESS
CITY STATE ZIP

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. C-v.Lve174,-2.tc Po sr 4,4/ 7 .- 605,,t i LT/iv1V
NAME TITLE OR AUTHORITY
3 1 f
IGNATURE DATE
24
I, A4e Hoc l)epo Q a , a Notary Public of the County of
(4 MP v T r, State of North Carolina, hereby certify that
17Vri ?.l✓4 .--- 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 day of Mid( , 20.2
'0001t l i t i it/Cli,a,,�
, 12: /,.... 160
;�‘' Mach -�
Notary qo� ,..... •o 1
s „ - • , �.
;0 0C A R Y .,c,
My commission expires 4V o� = i, p 0G ;2
iiiiitiliilstO,