NCC231085_FRO Submitted_20230425

•
WILSON
Noun ......
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)
Field Name Description Comments
PROJECT Tracking
number Bartlett Job No.23-033
Complete Application Received date
Application/NOI
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 1542 other than SFE(30000)=1522,others=blank
Project or Site name Full House Storage
Site Street Address 4913 NC 58 Hwy.
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27896
Non-Government=POF(default)
Government-County =CNG
Government-Federal=FDF
Site/Facility Type of Government-Municipal=MWD
Ownership POF Organization Government-State=STF
Approximate Activity
Start Date Summer 2023
Total Acres of
Distrubance 2.1
FRO-First Name Sherrie **MUST be Financially Responsible Owner Person**
FRO-Last Name Chaffin **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name Skye Partners,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address [e-mail] **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 19000 Davidson Concord Rd. **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text N/A **MUST belong to Financially Responsible Owner**
FRO-Mailing City Davidson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 28036-7869 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.784
Longitude:Decimal
Degrees -77.951

W I LSO
(it)ACRES TO BE DISTURBED 2,1 X S150.00/ACRE=$315.00
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.)
In case of a violation please list the preferred contact(either the financially Responsible Person or Registered Agent on the line
below:
Sherrie Chaffin 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.)
3/Ze/z-3
Date
Manager,Skye Partners,LLC
Title or Authority
Signature
Sherrie Chaffin
Type or Print Name
'CO.A )Q U1 f'4 Sr, ,a Notary Public of the County of M'e-C. e�U ,State of North Carolina
hereby certifies
es', 1)r (ltl C- C hQ! 1 jtf l personally appeared before me this day and under oath acknowledged that the
above form was executed by him.witness my hanci<nd notary seal,this /20� I� day of t, )t r 1(r7
.3.
(Notary Public).'QCS-,—,\
My commission expires U\' R 1 cC-i SEAN RUPERT, SR
IIIf Notary Public
Rockingham Co.,North Carolina
My Commission Expires July 21,2024