NCC243437_FRO Submitted_20241105

TOWN of
` WAKE FOREST
.¢t-- -_ '.
Individual Lot Land Disturbance
Financially Responsible Ownership Form
All builders and developers disturbing land in a subdivision (common plan of development) are required to have
a Land Disturbance Permit, even if the disturbance is less than one acre. Erosion Control measures must be
installed prior to any grading or construction on site.The site shall be inspected for maintenance needs weekly
and after each storm event, whichever is sooner. Please refer to the NC Erosion and Sediment Control Planning
and Design Manual for specific guidance as it relates to installation and maintenance.Additional details
regarding Erosion and Sediment Control can be found in the Unified Development Ordinance under Section
12.3.
Land Disturbance Fee:The application fee of$65 per lot is due at the time of submittal.
*Town of Wake Forest fees and charges are subject to changes without notice. Please call 919-435-9510 to
confirm current fees and charges.
Please contact the Town of Wake Forest Engineering Department regarding any questions at 919-435-9510,
or email Jessica Watkins at [e-mail].
Project Information
Project Name: Stonegate lot 8-9
Tax Pin Number: 1748653838 /3914 Zoning: GR 10
Location/Address of Tract: 2620/2616 Silver Gate Ct
Subdivision: StoneGate
Deed Book: 2023 Page: 2237
Lots Number(s): 8 , 9
Total Number of Lots: 2 Total Tract Acreage: .32
Total Acreage Disturbed (including off-site utilities and roadwork): .32
Fee: Total Number of Lots * $65/lot =

Property Owner
Please list any additional property owners on an attached sheet
Name: ICG Homes, LLC
Email: [e-mail] Phone: [phone]
Address: 4020 Wake Forest Rd. Ste.306; Raleigh, NC 27609
Contact Person
Person to contact in the event of erosion and sediment control issues
Name: Ryan Perry
Email: [e-mail] Phone: [phone]
Address: 4020 Wake Forest Rd. Ste.306; Raleigh, NC 27609
Financially Responsible Owner
Please list any additional FRO information on an attached sheet
Name: ICG Homes, LLC
Email: [e-mail] Phone: [phone]
Address: 4020 Wake Forest Rd. Ste.306; Raleigh, NC 27609
North Carolina Agent
Please include if the FRO above is not a resident of North Carolina
Name:
Email: Phone:
Address:
Partnership or Assumed Name
If the FRO is a partnership or other person engaging in business under an assumed name, attach a
copy of the certificate of assume name. If the FRO is a corporation, provide contact information.
Name:
Email: Phone:
Address:
Plan Preparation By
Name: Jeremy Taylor/Taylor Land Consultants, PLLC
Email: [e-mail] Phone: [phone]
Address: 1600 Olive Chapel Rd Ste. 140 Apex, NC 27502

Signatures
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.
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. I agree to provide corrected information should there be any change in the
information provided herein.
Name: Ryan Perry
Title or Authority: Owner Date: $ - Z - ZO 2J
Signature:
I, le, rn , Sit n , Notary Public of
the county of \A 1<.F, , State of North Carolina, herby certify
that R91 ?err 9 appeared personally before me
on this day and being duly sworn acknowledged that the above form was executed by him.
witness my hand and notarial seal, this 2.10 day of fILL9L4 S4- , 20 .
Notary Name:—Apssje, m ,
Commission Expires: Qa - t 1 - an a 5
Notary Signature:^ /),t4Atit/ Jryl.C�
Notary Seal:
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