NCC230173_FRO Submitted_20230120

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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 Fuquay-Varina Parkway (Truelove)
2. Location of land -disturbing activity: Highway/Street Truelove Road
3. Approximate date land -disturbing activity will commence: spring 2023
4. Type of development (residential, commercial, industrial, institutional,etC.): Linear (Roadway)
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 10.1 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Welch E-mail Address [e-mail]
Telephone [phone] Cell #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
(20 L 1 �-[ o M CMPA11 , i. L L �C &l *; . ea/61-
Name E-mail Address
12,Z 7cg Sc,�Nt i� ea%j �2i duir� 2Sb __
Current Mailing Address Current Street Address
C A±J A) 6 Z'ISIf
City State Zlp City State Zip
8. Deed Book No.!�yb 5 Page No. `1q l" 5'05' 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):
FV(4e ROIAt C�M�9cr..t l ILG G10 ckw' �aK C-LAVi H Ot
Name E-mail Address f 1
r P� t'T�01r'ur y . Go1M11
1225Cuss 1
Current Mailing Address Current Street Address
Go.r 3 N c�S �1
City State Ap City State Zip
Telephone Z(C6\t. ILL.
Town of Fuquay-Varina = 401 Old Honeycutt Road, Fuquay-Varjna, 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
herein.
Type or print name Title or uthorit
10 . ZS' • -42
Signature Date
I, M6!6� ,o ..SmLfid'Y1 of ,a Notary Public of the County of
State of North Carolina, hereby certify that(A'iyjS h(944 . VeLawid i2ti1/"2,' Wpe a personally
before me this day and being duly sworn acknowledge that We above form was ex�d by him.
Witness my hand and notarial seal, this day of Q (,!(-? b ey , 20 7,7_
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