NCC230518_FRO Submitted_20230224

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 Knightdale Gateway
2. Location of land -disturbing activity: Knightdale (Town Limits or ETJ)
Highway/Street Farmwell Rd. Latitude 35.797209 Longitude-78.528466
3. Approximate date land -disturbing activity will commence: February 27, 2023
4. Type of development (residential, commercial, industrial, institutional, etc.). Industrial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 37.5 Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jack R. Royal Jr. E-mail Address [e-mail]
Phone # [phone] Cell # 757-469-8765
7. Landowner(s) of Record (attach accompanied page to list additional owners): See next page for additional owners
Beacon KG LLC 704-597-7757 [e-mail]
Name(s) Telephone E-mail address
500 East Morehead Street, Suite 200 500 East Morehead Street, Suite 200
Current Mailing Address
Charlotte NC
Current Street Address
28202 Charlotte NC
28202
City State Zip City State Zip
8. Deed Book No. 19099 Page No. 574 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):
Beacon KG LLC [e-mail]
Name
500 East Morehead Street, Suite 200
Current Mailing Address
Charlotte NC
City State
Phone # [phone]
E-mail Address
500 East Morehead Street, Suite 200
Current Street Address
28202 Charlotte NC
Zip City
State
28202
Zip

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.
7 Landowner(s) of Record (attach accompanied page to list additional owners):
Beacon KG LLC 704-597-7757
Name(s)
500 East Morehead Street,
Current Mailing Address
Charlotte NC
City State
8 Deed Book No. 19107
Jon@beaco nd eve Eopment.com
Telephone E-mail address
Suite 200 500 East Morehead Street, Suite 200
Current Street Address
28202 Charlotte NC
28202
Zip City State Zip
Page No. 1551 Provide a copy of the most current deed
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Beacon KG LLC 704-597-7757 Jonbeacondevelopment.corn
Name(s)
500 East Morehead Street, Suite 200
Current Mailing Address
Charlotte NC 28202
City
8. Deed Book No.
State
19195
Telephone E-mail address
500 East Morehead Street Suite 200
Current Street Address
Charlotte NC 28202
Zip City State Zip
Page No. 77 Provide a copy of the most current deed.
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Beacon KG LLC 704-597-7757 [e-mail]
Name(s) Telephone E-mail address
500 East Morehead Street Suite 200
Current Mailing Address
Charlotte NC 28202
City
8. Deed Book No.
State Zip
19211 Page No.
500 East Morehead Street Suite 200
Current Street Address
Charlotte NC 28202
City State Zip
962 Provide a copy of the most current deed

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:
Advanced Civil Design, Inc.
[e-mail]
Name E-mail Address
51 Kilmayne Drive, Suite 102 51 Kilmayne Drive, Suite 102
Current Mailing Address Current Street Address
Cary NC 27511 Cary NC 27511
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:
Timothy C. Shaughnessy [e-mail]
Name of Registered Agent E-mail Address
500 East Morehead Street, Suite 200 500 East Morehead Street, Suite 200
Current Mailing Address Current Street Address
Charlotte NC 28202
City State Zip
Phone # [phone]
Charlotte NC 28202
City State Zip
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.
Jon L. Morris
Type or print name
Si
State of North Carolina, hereby certify that
personally before me this day and being duly sworn
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Witness my hand and notarial seal, this i_3� day of
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