NCC221664_FRO Submitted_20220429

HnancW esponssUflty/OwnersNp Form SPCA
See TOFU LDO, Section §9-1407 SOIL EROSION & SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Project Name Rowlands Grant
2. Location of land -disturbing activity: Highway/Street Hilltop Road
3. Approximate date land -disturbing activity will commence: May 2 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas):_ 77.2
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Raymond Rinker E-mail Address [e-mail]
Telephone [phone] Cell # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
JEN North Carolina 14, LLC ATTN: Ethan Leibowitz [e-mail]
Name E-mail Address
680 51h Avenue, 25th Floor 680 5th Avenue, 25th Floor
Current Mailing Address Current Street Address
New York, NY 10019 New York, NY 10019
City State Zip City State Zip
8. Deed Book No. 018943 Page No. 01515-01526 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):
Ashton Raleigh Residential LLC Raymond. Rinker(a7ashtonwoods.com
Name E-mail Address
900 Ridgefield Drive Suite 335 900 Ridgefield Drive, Suite 335
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone]
O,un of FuclUay-Marina . � 40? Old Honevcu'cc Road, Fucluay-Varina, NiC 2/526 -
[phone] HE futtuay-varina.org

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
Fuquay-Varina Land Development Ordinance and/or Land Disturbance Permit:
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A NIA
City State Zip City State Zip
Telephone NIA
(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:
NIA INIA
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
City State Zip
City State Zip
Telephone N/A
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.
Raymond Rinker Vice President Land Development
Type or print name Title or AuthcrntyZ
GignaTure Date
ry Public of the County of
State of North Carolina, hereby certify that ' ItiAilTIA. 114111ply appeared personally
before me this day and being duly sworn ackno)Aedged that the above form was executed by him.
Witness my hand and notarial seal, this day of 20
MARY HILL HEROLD wry
Sell NOTARY PUBLIC � � �u'� � _'Al' WAKE COUN 1Y, N.C. My commission expires
My Commission Expires 9-24-2026.