NCC232462_FRO Submitted_20230815

For TOWF Use Only Application #:
Project Name:
Date Received: Acres:
Date Approved. Fees Paid:
mA TOWN of
s . • WAKE FOREST
•
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.SEE THE 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=$1,000)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 GROVE 98 NORTHEAST QUADRANT COMMERCIAL LOT 5
1. TAX PIN NUMBER 1830876045
2. ZONING PUD RZ-18-15
3. LOCATION/ADDRESS OF TRACT 0 DR. CALVIN JONES HIGHWAY

4. SUBDIVISION N/A LOT#N/A
5. DEED BOOK 019321 PAGE 00349-00352
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT COMMERCIAL
7. TOTAL NUMBER OF UNITS N/A
8. PERCENT IMPERVIOUS SURFACE 57 • 796
9. TOTAL TRACT ACREAGE: 3 . 95
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF-SITE UTILITIES AND ROADWORK): 4 • 0 8
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 G98 COMMERCIAL PH II LLC E-MAIL MARK. HEBARD@STILES . COM
ADDRESS201 E LAS OLAS BLVD . STE . 1200 FORT LAUDERDALE, FL 33301-4434
PHONE [phone] CELL
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND-DISTURBING ACTIVITY:
NAME TAYLOR HOLLINGSHEAD E-MAIL [e-mail]
ADDRESS 418 S . Dawson St . Raleigh, NC 27603
PHONE [phone] CELL

14. PLANS PREPARED BY JORDAN M. PETERSON
ADDREss418 South Dawson Street Raleigh, NC 27601
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
DWQ 401 Permit
USACOE 404 Permit
NCG010000 Permit COC
EROSION &SEDIMENT CONTROL SURETY
APPROXIMATE DATE LAND-DISTURBING ACTIVITY WILL COMMENCE: 0 7 . 2 5 . 2 02 3
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.
PROJECT MANAGER 07 . 18 . 2023
SIGNATURE TITLE 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):
G98 COMMERCIAL PH II LLC MARK. HEBARD@STILES . COM
NAME EMAIL
201 E LAS OLAS BLVD . STE 1200
ADDRESS
FORT LAUDERDALE FL . 33301
CITY STATE ZIP CODE
980-282-1002
PHONE CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
CORPORATION SERVICE COMPANY CSCGLOBAL.COM OR [e-mail]
NAME EMAIL
2626 GLENWOOD AVE . STE . 550
ADDRESS
RALEIGH NC 27608
CITY STATE ZIP CODE
1-800-927-9801 EXT . 62827
PHONE CELL
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:
CORPORATION SERVICE COMPANY JAMIE . STEELE@CSCGLOBAL . COM
NAME OF REGISTERED AGENT E-MAIL ADDRESS
2626 GLENWOOD AVE . STE . 550
ADDRESS
RALEIGH NC 27608
CITY STATE ZIP

1-800-927-9801 EXT . 62827
PHONE 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.
JUSTIN SIEMENS PRESIDENT, CAROLINAS DIVISION
NAME TITLE OR AUTHORITY
% ram -7/Qr( 5
SIGNATURE DATE
I, i AGAN TART PA i><. , a Notary Public of the County of
State of North Carolina, hereby certify that
(warn-n 1:0 ,1 Si4.rsmerl 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 oZ) day of emu. 1 , 20 A3
chns- yril "earl Pari
Notary
tJIOTARY
My commission expirestWX7
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