NCC242273_FRO Submitted_20240725

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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: LiveDo-2024 Warehouse Expansion
PROJECT LOCATION:4925 LAMM RD.WILSON, NC 27896
APPROXIMATE PROJECT START DATE:July 23, 2024
(#)ACRES TO BE DISTURBED 15.8 X$150.00/ACRE=$2,370.00
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.)
LiveDo,USA, Inc. (Takuya Hishikawa- President)
Name(Person or Firm)
4925 LAMM RD.
Street Address(No P.O.BOX)
WILSON, NC 27896
City,State,Zip
[phone]
Telephone#
Fax#
hishikawa959©livedo.jp
E-mail address
Registered agent for the person or firm who is financially responsible:
N/A
Name(Person or Firm)
Street Address(No P.O.BOX)
City,State,Zip
Telephone#
Fax#
E-mail address
PROJECT NAME: LiveDo-2024 Warehouse Expansion

WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
LiveDo USA, Inc. (Takuya Hishikawa-President) 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.)
6/25/2 2 �
Date
President
Title or Authority
Signature
Takuya Hishikawa
Type or Print Name
President 6/Of/202,71
Title Date
//L / ' !�"� ,a Notary Public of the County of / V -L
State of North Carolina hereby certifies
71'1'/t J��--C// /-(' )r o. personally appeared before me this day and under
oath acknowledged that the above form was executed by him.
74.4
Witness my hand and notary seal,this 23 day of ✓ .00 2 7'.
' t
�f�`
(Notary Public) l �
PAULA HIBBLER
NOTARY PUBLIC
�// Nash County
My commission expires i�/J7 try 7`%2a7 North Carolina
J My Commission Expires January 4,2027