NCC233287_FRO Submitted_20231103

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 Kiddie Academy & Fresenius Kidney Center
2. Location of land-disturbingactivity: Knightdale
(Town Limits or ETJ)
Smithfied Road&McKnight Drive 35.793316 -78.487310
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence: December 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):3.47
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Neal Bates E-mail Address [e-mail]
Phone# [phone] Cell#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Henry H. Knight
Name(s) Telephone E-mail address
6020 Watkins Road
Current Mailing Address Current Street Address
Wendell NC 27591
City State Zip City State Zip
8. Deed Book No,006572 Page No.00379 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):
Primax Properties, LLC [e-mail]
Name E-mail Address
1100 E. Morehead Street
Current Mailing Address Current Street Address
Charlotte NC 28204
City State Zip City State Zip
Phone# [phone]

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:
Bowman North Carolina, Ltd. [e-mail]
Name E-mail Address
4006 Barrett Drive, Suite 104
Current Mailing Address Current Street Address
Raleigh NC 27609
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:
William Seymour [e-mail]
Name of Registered Agent E-mail Address
1100 E. Morehead Street
Current Mailing Address Current Street Address
Charlotte NC 26204
City State Zip City State Zip
Phone# [phone]
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.
Neal Bates Director
Type or print name Title or Authority
09/28/2023
Signature Date
I, •D{-v C S41 ktngtr , a Notary Public of the County of I r1 b IV
State of North Carolina, hereby certify that e3,1 k-25 appeared
personally before me this day and being dulyl sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 0.0 day of Se..- "a bw , 20S
,,,, ALLEN'
G S G S
aittar/-
• otary
Seal - € Comm,ExP• _.v r
�My2_�3_202a 'Z= My commission expires a - ,� o�n
0a%
kfA'0 "'••Pu e ,
O
,,,,,,, � ���G,•••°,U R G '•