NCC240413_FRO Submitted_20240214

WAKE COUNTY 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 Wake
WAKECounty Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORM CAROL N.. Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name L&W Building Addition & Parking Lot Expansion
2. Location of land-disturbing activity: Jurisdiction City of Wake Forest (Wake Co. or Municipality)
Highway/Street N White St Latitude 35.9942468 Longitude -78.4920589
3. Approximate date land-disturbing activity will commence: July 1, 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): 0.74 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Sam Albea E-mail Address sama©thecontineogroup.com
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
L&W Supply Corporation
Name(s) Telephone Fax or E-mail address
1 ABC Pkwy 1 ABC Pkwy
Current Mailing Address Current Street Address
Beloit, WI 53511-446 Beloit, WI 53511-446
City State Zip City State Zip
8. Deed Book No. 17402 Page No. 0470 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):
L&W Supply Corporation [e-mail]
Name E-mail Address
1 ABC Pkwy 1 ABC Pkwy
Current Mailing Address Current Street Address
Beloit, WI 53511-446 Beloit, WI 53511-446
City State Zip City State Zip
Telephone Fax Number

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 Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Daniel Hinkle [e-mail]
Name E-mail Address
1307 White St
Current Mailing Address Current Street Address
Wake Forest, NC, 27587
City State Zip City State Zip
Telephone Fax Number
(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:
Dan Piche [e-mail]
Name of Registered Agent E-mail Address
One ABC Parkway
Current Mailing Address Current Street Address
Beloit, WI 53511
City State Zip City State Zip
Telephone Fax Number
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.
Dan Piche President
Type or print name Title or Authority
Dalt R he' 3/7/2023
Dan Pinkie'(Mar 7,2023 17,55 CST)
Signature Date
I, ,e/,__4y X_ ,�Vi?T , a Notary Public of the County of p G4—
(4/1 S�NSf ti?State of Narita L.,fatma, hereby certify that 0/4/C1 t/Z
, 4o1,2d1y 4-X&II7is.J 7 "r d aa(/ylsicrr
Witness my hand and notarial seal, this 43 day of ,PC , 20 a3
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GIND " FG,,� otary
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‘jQ • a My commission expires ��1�.
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For TOWF Use Only Application Irk
Project Name:
Date Received: Acres:
Date Approved: Fees Paid:
, w
TOWN of
r
= 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 1/2 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 L&W BUILDING ADDITION & PARKING LOT EXPANSION
1. TAX PIN NUMBER 1851075309
2. ZONING LI
3. LOCATION/ADDRESS OF TRACT 1307 N White St

4. SUBDIVISION LOT)#
5. DEED BOOK 17402 PAGE 0470
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT Building addition & parking lot expansion
7. TOTAL NUMBER OF UNITS 1
8. PERCENT IMPERVIOUS SURFACE 71.3% existing, 80.1% proposed
9. TOTAL TRACT ACREAGE: 4.18 acres
10. TOTAL ACREAGE DISTURBED(INCLUDING OFF-SITE UTILITIES AND ROADWORK): 0.74 acres
11.AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE 0.8 acres *$S00/ACRE = $ 400.00
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 L&W Supply Corporation E-MAIL
ADDRESS 1 ABC Pkwy, Beloit, WI 53511-4466
PHONE_ CELL
13. PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND-DISTURBING ACTIVITY:
NAME Sam Albea E-MAIL [e-mail]
ADDRESS 755 Commerce Dr, Decatur, GA 30030
PHONE [phone] CELL

14. PLANS PREPARED BY Contineo Group
ADDRESS 755 Commerce Dr, Decatur, GA 30030
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 1st 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) N/A
MAINTENANCE AND OPERATION AGREEMENT N/A
NCDOT Encroachment/Driveway Permit N/A
DWQ 401 Permit N/A
USACOE 404 Permit N/A
NCG010000 Permit COC N/A
EROSION &SEDIMENT CONTROL SURETY N/A
APPROXIMATE DATE LAND-DISTURBING ACTIVITY WILL COMMENCE: July 1, 2023
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.
bar'cit,'.h/i k District Manager 3/7/2023
Daniel Hinkle(Mar 10,2023 13:45 EST)
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):
L&W Supply Corporation
NAME EMAIL
1 ABC Pkwy
ADDRESS
Beloit, WI 53511-446
CITY STATE ZIP CODE
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:
Daniel Hinkle [e-mail]
NAME EMAIL
1307 White St
ADDRESS
Wake forest, NC 27587
CITY STATE ZIP CODE
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:
Dan Plc h e [e-mail]
NAME OF REGISTERED AGENT E-MAIL ADDRESS
One ABC Parkway
ADDRESS
Beloit, WI, 53511
CITY STATE ZIP

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.
Dan Piche President
NAME �j TITLE OR AUTHORITY
e
Dam �' ' 3/7/2023
Dan Piche'(Mar 7,2023 17:55 CST)
SIGNATURE DATE
I, //l/2)r /- , a Notary Public of the County of
Guy sue&/&/J iccGJ0au46
, State of-Pstarth-00+441.ina, hereby that
P/GN a �GALtY E)Ci_cv In
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Witness my hand and notarial seal, this /3 day of Aej,ec/_t ,•
20a2.
of NAO Tq .
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My commission expires 94/27 "

= TOWN of
WAKE FOREST
LAND DISTURBING (E&SC) PERMIT PLAN SUBMITTAL CHECKLIST
(SUBMITTER TO PLACE A CHECK MARK NEXT TO EACH ITEM)
1. LOCATION/VICINITY MAP
2. EXISTING AND PROPOSED COUNTOURS, INCLUDING OFFSITE
3• CLEARLY DELINEATED BOUNDARIES OF LAND DISTURBANCE WITH ACREAGE
4. SOILS AREA MAP
5. DRAINAGE AREA MAP
6. EXISTING UTILITY EASEMENTS,STORM DRAINAGE, BASINS,LEVEL SPREADERS
7. EXISTING LOT LINES, LOT NUMBERS,SURROUNDING PROPERTY OWNERS
8. STREAM CENTERLINES,STREAM BUFFERS,WETLANDS, FLOODPLAINS
9 TEMPORARY EROSION CONTROLS TO BE SHOWN ON PLANS:
1. EROSION CONTROL CALCULATIONS(SEDIMENT BASIN,SEDIMENT TRAP,
SKIMMER, DITCH, ETC...)
2. SKIMMER BASINS REQUIRED FOR DRAINAGE AREA OVER 5 ACRES
3. IF PAM IS TO BE USED ONSITE FOR ANY APPLICATIONS,CALCULATIONS FOR
APPLICATION RATES AND SPECIFICATIONS MUST BE SHOWN.IN ADDITION,
SOIL TESTS MUST BE TAKEN TO DETERMINE CORRECT SOIL CHARGE AND
PRODUCT TYPE PRIOR TO USE.
4. CONSTRUCTION ENTRANCE 50 FOOT MINIMUM WITH WOVEN 20#
TENSILE STRENGTH FABRIC UNDERNEATH
5. SILT FENCE-METAL POSTS WITH WIRE SPACED AT 6 FEET
6. HARDWARE CLOTH OUTLETS(SPECIAL SEDIMENT CONTROL FENCE)
7. TREE PROTETION FENCE WITH "DO NOT ENTER TREE PROTECTION AREA"
SIGN IN ENGLISH AND SPANISH
i. REQUIRED AROUND PERIMETER OF
PROPERTY

ii. REQUIRED AT BUFFER ZONES
iii. REQUIRED IN TREE SAVE AREAS(AROUND
DRIP LINE)
S. DIVERSION DITCHES
L 9. INLET PROTECTION
10. EROSION
11. PERMANENT EROSION/STORMWATER CONTROLS
1. STORM WATER CALCULATIONS,Q PRE,Q POST,
IMPERVIOUS
ii. PROPOSED STORMWATER EASEMENTS(RECORDED)
iii. MAINTENANCE AND OPERATION AGREEMENT
iv. PROFESSIOANLLY SURVEYED AND ENGINEER STAMPED AS-
BUILTS OF STORMWATER PONDS/Bl0 CELLS, LEVEL
SPREADERS,STORM DRAINAGE INVERTS,TOPS, GRATES,
SLOPES, LENGTH,SIZE,ETC...
v. PERMANENT DITCHES WITH MATTING
J to. EROSION PERMIT NOTES:(please add to plans)
1. A LAND DISTURBING(E&SC)PERMIT IS REQUIRED FOR PROJECTS OVER 0.50
ACRE.
IF MULTIPLE LOTS WITH LAND DISTURBANCE OVER 0.50 ACRE TOTAL ARE
EITHER CONTIGUOUS OR NON-CONTIGUOUS IN THE SAME SUBDIVISION,BY
THE SAME BUILDER/OWNER,A LAND DISTURBING PERMIT IS REQUIRED.
THE COST OF THE PLAN REVIEW AND PERMIT IS$500/ACRE ROUNDED UP(1.1
ACRES=2 ACRES @$500/ACRE=$1,000).THE FEE IS DUE AT TIME OF PLAN
SUBMITTAL. DEVELOPER IS RESPONSIBLE FOR INFORMING BUILDER OF E&SC
PERMIT REQUIREMENTS ON INDIVIDUAL LOTS.
DISCLAIMER:Town of Wake Forest fees and charges are subject to change
without notice.Please call919-435-9443 to confirm current fees and charges.
2. IF ADDITIONAL ACREAGE IS ADDED TO AN EXISTING PERMIT REVISED FORMS,
PLANS,AND ANY ADDITIONAL FEES MUST BE SUBMITTED.
3. IF OWNERSHIP OF A PROPERTY HAS CHANGED A REVISED FRO MUST BE
SUBMITTED.
4. IF A PROPERTY IS TAKEN OVER BY THE BANK,THE BANK SHALL CONTACT THE
TOWN AND REPAIR ALL EROSION CONTROL MEASURES TO TOWN/NCDENR
STANDARDS.THEY SHALL ALSO SUBMIT A NEW FRO FORM.
5. IF A PROJECT IS NOT COMPLETE WITHIN TWO YEARS,THE PLANS MUST BE
RENEWED AT$250/ACRE.A REVISED SET OF PLANS MAY BE SUBMITTED IF
ACREAGE HAS ALREADY BEEN DEVELOPED AND A CERTIFICATE OF OCCUPANY
HAS BEEN ISSUED.

6. AN EROSION PRECONSTRUCTION MEETING MUST BE HELD WITH THE TOWN OF
WAKE FOREST PRIOR TO START OF ANY WORK, INCLUDING INSTALLATION OF
EROSION CONTROL MEASURES, DEMOLITION,CUTTING TREES,AND
GRUBBING.
CALL ENGINEERING AT(919)435-9443 TO SET UP A MEETING.ALL PLANS MUST
BE SIGNED AND COPIES RETURNED TO THE TOWN 1 WEEK PRIOR TO
PRECONSTRUCTION MEETING.
7. THE OWNER,GENERAL CONTRACTOR,GRADING COMPANY,AND EROSION
CONTROL INSTALLER MSUT BE PRESENT AT THE PRECONSTRUCITON MEETING.
8. THE E&SC PERMIT WILL BE DISTRIBUTED AT THIS MEETING.
7.1. E&SC CONSTRUCTION SEQUENCE NOTES:(please add to plans)
1. PRIOR TO SCHEDULING THE PRECONSTRUCTION MEETING,THE EROSION AND
SEDIMENT CONTROL SURETY MUST BE SUBMITTED TO THE TOWN OF WAKE
FOREST.THE NCG010000 CERTIFICATE OF COVERAGE MUST BE OBTAINIED BY
THE PERMITTEE,WHEN APPLICABLE.A COPY OF THE COC MUST BE SUBMITTED
TO THE TOWN.
2. AFTER THE PRECONSTRUCITON MEETING IS HELD,THE CONTRACTOR CAN
INSTALL INITIAL EROSION CONTROL MEASURES ONLY.THIS INCLUDES BUT IS
NOT LIMITED TO CONSTRUCTION ENTRANCE,SILT FENCE, PERIMETER
DIVERSION DITCH, CHECK DAMS(ROCK OR WADDLE TYPE),TREE PROTECTION
FENCE, EXISITNG INLET PROTECTION,SKIMMER SEDIMENT BASINS,AND
SEDIMENTTRAPS. CLEAR ONLY AS NECESSARY TO INSTALL THESE MEASURES.
3. CONTRACTOR IS RESPONSIBLE FOR E&SC WEEKLY INSTALLATION AND
MAINTENANCE LOG INCLUDING DATES OF TEMPORARY/PERMANENT
GROUND COVER,A RAIN GAUGE,COPY OF TOWF SIGNED PLANS ONSITE,
REVISED SIGNED PLANS, NPDES LOG,AND CONSTRUCTION BOX MUST BE
PRESENT AND EASILY ACCESSABLE ONSITE.
4. ONCE MEASURES ARE INSTALLED,CONTRACTOR/FRO TO CALL TOWF FOR AN
INITIAL INSPECTION.IF SITE PASSES INSPECTION,A CERTIFICATE OF
COMPLIANCE WILL BE ISSUED.CONTRACTOR CAN NOW BEING CLEARING,
GRUBBING,AND GRADING.
5. CONTRACTOR TO MAINTAIN ACCESS ROAD FOR EMERGENCIES AT ALL TIMES.
6. PHASE PROJECT TO LEAVE AS LITTLE GROUND OPEN AS POSSIBLE.
7. TEMPORARILY SEED,STRAW AND TACK OR HYDROSEED WITHIN 14 DAYS OF
ANY PHASE OF GRADING, INCLUDING SLOPES.SEED BASINS AND DITCHES
IMMEDITEALY AFTER CONSTRUCTION.
8. PRIOR TO REMOVAL OF TEMPORARY MEASURES,TOWN MUST APPROVE
REMOVAL.ALL AREAS ABOVE TEMPORARY MEASURE MUST HAVE 85%
GROUND COVER.
9. THE TOWN OF WAKE FOREST CONSTRUCTION INSPECTOR WILL EVAULATE THE
SITE ATLEAST ONCE A MONTH.A COPY OF THE INSPECTION FORM WILL BE
EMAILED TO THE FRO.THE WEEKLY EROSION LOG AND NPDES LOG MUST BE
ONSITE AND AVAILABLE FOR REVIEW.
10. IF THE SITE IS FOUND OUT OF COMPLIANCE A NOTICE OF VIOLATION WILL BE
ISSUED GIVING THE CONTRACTOR/FRO 7 WORKING DAYS TO REMEDY THE
PROBLEM. IF THE SITUATION IS NOT RESOLVED WITHIN THE TIME PERIOD A
FINE MAY BE ISSUED.
11. IF SEDIMENT LEAVES THE SITE A FINE MAY BE ISSUED UP TO$5,000 PER DAY

PER VIOLATION. IF SEDIMENT ENTERS A BUFFER,STREAM,OR WETLAND
NCDWQ WILL BE NOTIFIED.THEY MAY ISSUE FINES UP TO$25,000 PER DAY PER
VIOLATION.
12. CALL THE TOWN UPON COMPLETION FOR A FINAL EROSION INSPECTION.A
PUNCHLIST MAY BE GENEREATED ADDRESSING ANY REMAINING ITEMS.
THERE MUST BE 85%GROUNDCOVER ON THE ENTIRE SITE PRIOR TO A
CERTIFICATE OF OCCUPANCY. IF THE SITE IS FOUND TO BE IN COMPLIANCE
AN EROSION CERTIFICATE OF COMPLETION WILL BE ISSUED. AFTER THE
COMPLETION OF THE PROJECT,SUBMIT A NOTICE OF TERMINATION TO END
COVERAGE UNDER THE NCGO1000 PERMIT.

Financial Responsibility Form
Final Audit Report 2023-03-10
Created: 2023-03-07
By: Jessica Hansrote([e-mail])
Status: Signed
Transaction ID: CBJCHBCAABAAigrUdSgQ7LShRHS2xCzuk2H1mITOo21J
"Financial Responsibility Form" History
t Document created by Jessica Hansrote([e-mail])
2023-03-07-4:54:08 PM GMT
'-. Document emailed to [e-mail] for signature
2023-03-07-5:10:02 PM GMT
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6© Signer [e-mail] entered name at signing as Dan Piche'
2023-03-07-11:55:28 PM GMT
d© Document e-signed by Dan Piche' ([e-mail])
Signature Date:2023-03-07-11:55:30 PM GMT-Time Source:server
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t Email viewed by [e-mail]
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d© Signer [e-mail] entered name at signing as Daniel Hinkle
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C5e, Document e-signed by Daniel Hinkle([e-mail])
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O Agreement completed.
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