NCC241792_FRO Submitted_20240701

TOWN OF KNIGHTDALE FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Town
of Knightdale Unified Development Ordinance before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by Town of
Knightdale, Public Works Department, Stormwater Division. (Please type or print and, if the
question is not applicable, place N/A in the blank.)
Part A.
1. Project Name Allen Park Ph 2
Knightdale 2. Location of land-disturbing activity: (Town Limits or ETJ)
Old Milburnie Rd 35.824886 -78.514178
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:
Q2 2024
4. Type of development (residential, commercial, industrial, institutional, etc.):
Residential
5. Total acrea a disturbed or uncovered (including off-site utilities and borrow/waste
areas):44.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Brian Massengill E-mail Address [e-mail]
Phone# [phone] Cell#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Allen Park, LLC [phone] [e-mail]
Name(s) Telephone E-mail address
506 Main Street, Suite 300 506 Main Street, Suite 300
Current Mailing Address Current Street Address
Gaithesburg MD 2087F3 Gaithesburg MD 20878
City State Zip City State Zip
8. Deed Book No. 18861 Page No.2614-2619 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Allen Park, LLC [e-mail]
Name E-mail Address
506 Main Street, Suite 300 506 Main Street, Suite 300
Current Mailing Address Current Street Address
Gaithesburg MD 20878 Gaithesburg MD 20878
City State Zip City State Zip
Phone# [phone]

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Town of Knightdale Erosion and Sedimentation Control Ordinance and/or
Land Disturbance Permit:
Brian Massengill [e-mail]
Name E-mail Address
1903 N Harrison Ave, Suite 101 1903 N Harrison Ave, Suite 101
Current Mailing Address Current Street Address
Cary NC ,,,,,. Cary NC 27513
City State Zip City State Zip
Phone# [phone]
(b) 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
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone#
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.
Brian Masengill Authorized Person
Type print name Title or Authority
1'4_0;2 W/D/Z fL
Signature Date
I,_clam!ron 1. M 6c-iton I\ , a Notary Public of the County of 361(1 5 v1
State of N(, , hereby certify that lavetel -T. Mra.55en ;(
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 10 day of 3ilit(_ , 20 ay
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Seal /< - • (��. Notary
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