NCC221830_FRO Submitted_20220512

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FUOUAW-1`AP I NA
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Financial Responsibility/Ownership Form SPCA
See TOFV LDO, Section §9-1407 SOIL EROSION & SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Protect Name Royal Creek - Lot 4
2. Location of land -disturbing activity: HighwaylStreet 7750 Ten -Ten Road. Fuauav-Varina_ NC
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Type of development (residential, commercial, industrial, institutional,etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 0.97 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Barrett Blackburn E-mail Address bbb;�caaj, cidaeoroo.corn
Telephone [phone] Cell #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
IT i 6 C , lso rPr�s77tr Jr � i P/P- C1t..gG;.4ear D P. 6 4 .M
Name '"A k4 J e. E-mail Address
831 E Morehead St Ste 245 831 Morehead t Ste 245
Current Mailing Address Current Street Address
Charlotte, NC 28202
City State Zip City State Zip
8. Deed Book No. 17511 Page No._1263 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):
CqA ,,j fyQ - Fy, C L 1a1�.. T /r� r cf�. S.. JJ lLO, i9e P CiA
Name E-mail Address
83 1 E.�"tors��� S,1} ? „ : 2y gJ1 E. )g0pe.Az_t,4 Sf� Sw,�t 2 ys
Current Mailing Address Current Street Address
CAA, /, ir7 6 aW0444_1ft z. f xi 2
City State Zip City State Zip
Telephone 70'1 - z,, 3 J. 2 3 93
Town of Fuquay-Varina = 401 Old Honeycutt Road, Fuquay-Varina, NO 27526 w
[phone] = fuquay-varina.org

2. (a) If the Financially Responsible Warty 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
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City State Zip
Telephone
(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:
GEORGE L. MALOOMIAN GLM [e-mail]
Name E-mail Address
831 E MOREHEAD STREET SUITE 245 831 E MOREHEAD STREET SUITE 245
Current Mailing Address Current Street Address
CHARLOTTE NC 28202 CHARLOTTE, NC 28202
City State Zip City State Zip
Telephone [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. J.
Type or print name Title or Authority
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S natur ,,.,, ,. _.
Date
a NotaryPublic of the County of �3
State of North Carolina, hereby certify that ML"\ 3. t'r, , �4tr r appeared persd nally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 3 ~ day of 20 •1 1
,j "i iL 1 RICti 1
Seal
NOTARY, o,
PUBLIC
Notary
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My commission expires