NCC223881_FRO Submitted_20221121

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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. Project Name Redeemer Community Church
2. Location of land -disturbing activity: Highway/Street 152 Wagstaff Road
3. Approximate date land -disturbing activity will commence: October 2021
4. Type of development (residential, commercial, industrial, institutional, etc.)- Institutional
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 8.17 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Don Cur E-mail Address daon(a-)currven4.com
Telephone [phone] x101 Cell # 919-880-9857
7. Landowner(s) of Record (attach accompanied page to list additional owners):
_Redeemer Community Church — Adam Darnell [e-mail]
Name E-mail Address
PO Box 808
Current Mailing Address
111 Depot Street
Current Street Address
Fuauav-Varina. NC 27526 Fuquav-Varina, INC 27526
City State Zip City State Zip
8. Deed Book No. 017330
Page No. 01016
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):
Redeemer Community Church — Adam Darnell adam(LDredeemernc.ora
Name E-mail Address
PO Box 808 111 Depot Street
Current Mailing Address Current Street Address
Fuquav-Varina NC 27526 Fuquav-Varina. NC 27526
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina HE 401 Old Honeycutt Road, Fuquay-Varina, NC 27526
[phone] - fuquay-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
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:
Name
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City State Zip
Telephone
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
her in.
her
M Tarn e �I I V�--?OL5
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a Notary Public of the County of
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State of North Carolina, hereby certify that _ 1-V- C4-m )a rre t appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this c- 2-day of Ju (7' 20 2 I
CHRISTOPHER W. SMITH Notary
Notary Public
Seal Harnett Co,, North Carolina
My Cornmrssron Expires Aug. 25, 2024 My commission expires