NCC233538_FRO Submitted_20231130

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WILSON
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)
PROJECT NAME:3649 WARD BLVD. FILL AREA
PROJECT LOCATION:3649 Ward Blvd. Wilson, NC
APPROXIMATE PROJECT START DATE:9/20/23
(#)ACRES TO BE DISTURBED 1.5 X$150.00/ACRE=$225.00
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.)
Meraki Holdings Group, LLC (Robert Morkos Youseff)
Name(Person or Firm)
2117 Forest Hills Road
Street Address(No P.O.BOX)
Wilson, NC 27893
City,State,Zip
252-227-9463
Telephone#
N/A
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
Name(Person or Firm)
Street Address(No P.O.BOX)
City,State,Zip
Telephone#
Fax#
E-mail address
PROJECT NAME: 3649 WARD BLVD. FILL AREA

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WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Robert Morkos Youseff 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.)
9/15/23
Date
Preside
itle or Authori
Si tur
Robert Morkos Youseff
Type or Print Name
President 9/15/23
Title Date
T�� �\A' NS41)Y 1 ,a Notary Public of the County of \JU NI ,
State of No h Carolina hereby certifies
(Z-Obe.c M-0( OS `\0 L4. 4 personally appeared before me this day and under
oath acknowledged that the above form waswa executed by him.G \ ` �('
Witness my hand and notary seal,this d I day of J Q. '�J'�Lh1J,p.Q.V,
(Notary Public) •
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1-19
My commission expires
i 711012026
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