NCC223572_FRO Submitted_20221025

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NOR,H CAROi.INA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name WENDELL FALLS (LOT 18) PROPOSED SENIOR LIVING DEVELOPMENT
E
Location of land -disturbing activity: Jurisdiction Town of Wendell
(Wake Co. or Municipality)
Highway/Street Wendell Falls Parkway Latitude 35.777968 Long itude-78.435719
3. Approximate date land -disturbing activity will commence: 12/01/2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including oft -site utilities and borrow/waste
areas): 6.40
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Krusell
E-mail Address [e-mail]
Telephone [phone] Cell # 704-467-0983 Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
FC WF, LLC (Attu. Kevin Woodley) [phone] [e-mail]
Name(s)
7315 WISCONSIN AVE., SUITE 925W
Current Mailing Address
BETHESDA, MD 20814
Telephone Fax or E-mail address
7315 WISCONSIN AVE., SUITE 925W
Current Street Address
BETHESDA, MD 20814
City State Zip City State Zip
8. Deed Book No. BM2022 Page No. 01422 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):
FC WF, LLC (Attn. Kevin Woodley) [e-mail]
Name E-mail Address
7315 WISCONSIN AVE., SUITE 925W 7315 WISCONSIN AVE., SUITE 925W
Current Mailing Address Current Street Address
BETHESDA, MD 20814 BETHESDA, MD 20814
City State Zip City State zip
Telephone [phone] Fax Number NIA

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 Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Scott Krusell
Name
900 Perimeter Park Drive STE B3
Current Mailing Address
Morrisville, NC, 27560
C ity
Telephone [phone]
[e-mail]
E-mail Address
900 Perimeter Park Drive STE B3
Current Street Address
Morrisville, NC, 27560
State Zip City
Fax Number NIA
State Zip
(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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
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.
Type or print name
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Title orb Authority
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Date
I, t3of\e-;� a Notary Public of the County of
State of North Carolina, hereby certify that `3c appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
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WitnesEal seal, this day of 20�
Norqf?y
�.r Notary
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My commission expires
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