NCC233454_FRO Submitted_20231121

WILSON
NORTH CAROLINA
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
Complete Application Received date
Application/N01
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 1521 other than SFE(30000)=1522,others=blank
Project or Site name BEDFORD PLACE PHASE II
Site Street Address At End of Westwood Avenue
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 July 15,2023
Total Acres of
Distrubance 6.6 Acres
FRO-First Name Tom **MUST be Financially Responsible Owner Person**
FRO-Last Name Benson **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name FWB Development Co.,Inc. **MUST belong to Financially Responsible Owner**
FRO-eMail Address [e-mail] **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 712 Goldsboro Street SW **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text **MUST belong to Financially Responsible Owner**
FRO-Mailing City Wilson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27893 **MUST belon%to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.736
-77.968
Longitude:Decimal
Degrees

(#)ACRES TO BE DISTURBED 6.6 AC X$150.00/ACRE=$990.00
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:
Ron Sutton
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.)
04-11-23
Date
Preside)(0
Title u
Signature
Thomas Benson
Type or Print Name
President 04-11-23
Title Date
TQi,e 4 1' M ann;n Y ,a Notary Public of the County of I las►1 ,State of North Carolina
hereby certifies 1 a
�k0Y Q W.w. ICn h personally appeared before me this day and under oath acknowledged that the
above form was executed by him.
Witness my hand and notary seal,this 12 4" day of "iUY►t- , 2023 .
(Notary Public) 1Ø'k "Ts Mal ,.0�ERT T. 4, "'
%
My commission expires 1124 C0I. ? 'L _
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'",,,COUNT'(,�'``.``.