NCC222109_FRO Submitted_20220613

For TOWF Use Only Application
Project Name:
Date Received: Acres:
Date Approved: Fees Paid:
WAKE FORES
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. SEETHE 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,OOO) 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 Mason Oaks Parcel 3
1. TAX PIN NUMBER 1842-34-7743
2. ZONING GR-10CD
3. LQCATION/ADDRESS OF TRACT
Edgemore Trail -- Mason Oaks Subdivision

4. SUBDIVISION Mason Oaks Parcel 3
5. DEED BOOK 2168 PAGE 1448
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT Townhomes
7. TOTAL NUMBER OF UNITS 21
8. PERCENT IMPERVIOUS SURFACE 40.7%
9. TOTAL TRACT ACREAGE: 4.52
LOT# 1-21
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF -SITE UTILITIES AND ROADWORK): 4.6
11. AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE 5 * $500/ACRE = $ 2,500
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):
NAME Jeff Grote c/o Greenpointe, LLC E-MAIL [e-mail]
ADDRESS 7201 Creedmoor Rd, Suite 140 - Raleigh, NC 27613
PHONE [phone] CELL
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND -DISTURBING ACTIVITY:
NAME Jeff Grote c/o Greenpointe, LLC E-MAIL [e-mail]
ADDRESS 7201 Creedmoor Rd, Suite 140 - Raleigh, NC 27613
PHONE [phone] CELL

14. PLANS PREPARED BY David Arnold, PE c/o Arnold Land Design, PLLC
ADDRESS 113 Yosemite Court - Holly Springs, NC 27540
EMAIL [e-mail]
PHONE [phone]
CELL
15. DOCUMENTS SUBMITTED (SUBMITTER TO PLACE A CHECK MARK IN THE BOX):
FEES ($500 per acre rounded up, due upon 15t review)
X
FINANCIAL RESPONSIBILITY OWNER FORM
X
COMPLETED PLAN CHECKLIST
X
PLANS (to be submitted with construction set)
X
E&SC CALCULATIONS (1 copy)
X
STORMWATER CALCULATIONS (1 copy)
X
MAINTENANCE AND OPERATION AGREEMENT
X
NCDOT Encroachment/Driveway Permit
NIA
DWQ 401 Permit
N/A
USACOE 404 Permit
NIA
NCG010000 Permit COC
EROSION & SEDIMENT CONTROL SURETY
X
APPROXIMATE DATE LAND -DISTURBING ACTIVITY WILL COMMENCE: June 2022
Submitted after approval
THE SOIL EROSION AND SEDIMENTATION CONTROL PLAN, supporting documents, maps and
computations submitted for the above tract conform to the requirements of all applicable
sections of the Town of Wake Forest Erosion & Sedimentation Control Ordinance outlined in
the UDo.
SIGNATURE
Project Manager
TITLE
04105/2022
DATE

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):
Jeff Grote c/o Greenpointe, LLC [e-mail]
NAME EMAIL
7201 Creedmoor Rd, Suite 140
ADDRESS
Raleigh NC 27613
CITY 5TATE ZIP CODE
919-971-5200
PHONE CELL
2, IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
NIA NIA
NAME EMAIL
NIA
ADDRESS
NIA
CITY STATE ZIP CODE
NIA NIA
PHONE CELL
IF THE FINANCIALLY RESPONSIBLE PARTY 1S 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.
NIA NIA
NAME OF REGISTERED AGENT
NIA
ADDRESS
NIA
CITY STATE ZIP
E-MAIL ADDRESS

NIA
PHONE
NIA
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.
-r -
TITLE OR AUTRITY
DATE
I, I\Jovd tk) KC 161 !�( , , a Notary Public of the County of
( & �k-Q_ , State of North Carolina, hereby certify that
�1Y-G) 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 4,�0�1 day of /4dA,-J-1 , 20 -2Z
Notary
My commission expires