NCC241855_FRO Submitted_20240617

WILSON
NORTH CAROLIN
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.Q (*Indicate N/A if a question is not applicable)
PROJECT NAME: 1158 Place. (Pisa-re i-8 + I- C)
PROJECT LOCATION: 38401 CGSS/74 Way West', Wi/sop,NC 27896
APPROXIMATE PROJECT START DATE: 7/UUZI
(#)ACRES TO BE DISTURBED T_56 X$150.00/ACRE= 56 84L•
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.)
11/1%, Crr,4w 7o.- /,, E451-wood yo.++Gs o"(Ka/G yh, L L C
Name(Person or Firm)
700I Cree /, 0.. Rd., 514;/-e•//5
Street Address(No P.O.BOX)
ifede .N G. 2 76/3
City,State,Zip
9/9-y27- 2962.
Telephone#
Fax#
qc, i..i' o.-deeasfwooa/`io,ieso cow
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: /I58 PJACG. (Phase 14--B f- c)

•}ski
WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Ad Cif-etw fO,/ 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.)
S/7/29
Date
Vice )9/'cside.f+
Title or horlty /-
__---,, *
Signs e
�dy Cie aWICId
Type or Print Name
Vice i3eside.v* •5/7/2y
Title Date
'l e, SO Aik ,a Notary Public of the County of `-"IAV--e.- ,
State of North Caivaaher\ebyy`certifies
PI f`l Oc Ivyd personally appeared before me this day and under
oath acknowdged th. - aby.- .rm was executed by him.
Witness my hand .•d not , 4 ir day of IfYVLA ,44__..
(Notary Public) Ifni tt ``,``,\nnnn..q,,,,�i
-r F-- �,
-Lamm.-F•.,S
My commission expires iIll �, „A. . . ° r :`Q,,�� • +q,�.s1.
NO � '
TARP N ' =
PUBLic
6.
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