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HomeMy WebLinkAboutNCC231403_FRO Submitted_20230511 FUQJAY-VAR ! NA north corolino 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 Providence Oaks Ph 1 Off-site Roadway Plans 2. Location of land-disturbing activity: Highway/Street Ropers Road 3.Approximate date land-disturbing activity will commence: June 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): 7 acres 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Scott Cobb E-mail Address Scott.Cobb@pulte.com Telephone Cell#(919)291-8025 7. Landowner(s)of Record (attach accompanied page to list additional owners): Pulte Home Company, LLC Chris.Raughley( Pulte.com Name E-mail Address 1225 Crescent Green Drive Suite 250 Same Current Mailing Address Current Street Address Cary, NC 27518 Same City State Zip City State Zip 8. Deed Book No. 18878 Page No. 2277 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): 1. . O ML( LA M?04%1 LLC Name E-mail Address t22. 5" C.reSCtpk Gru-r. OytVc Current Mailing Address Current Street Address Co....4 nlC., 1711k City State Zip City State Zip Telephone _`141 B14e 11(2 ( Town of Fuquay-Varina E 401 Old Honeycutt Road, Fuquay-Varina, NC 27526 (919)552-1400 E 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 E-mail Address Current Mailing Address Current Street Address City State Zip 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 E-mail Address Current Mailing Address Current Street Address City State Zip 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. Chrib Raughlp VP Land Development Type or print nartM or Authority ROWA 3 • ' • a 2 Signature I V Date I, //1,2A1 Sai 51,Y14-1-r4 Kt , a Notary Public of the County of IA/ot State of North Carolina, hereby certify that C/Vi vi appeared personally before me this day and being duly sworn acknowledged that fdrm was executed by him. Witness my hand and notarial seal, this 1 day of /Vlatn•r/L , 20 2 PSME ' frtfl T9 - •.' i�, '-, Notary �. • ' • Seal �4!;�OAR y;;9 _ v-7l 2-7 zC My commission expires L\PUR *PuLteGroup TOWN OF FUQUAY-VARINA Check Number Vendor Number 42PER2100 Check Date 03/08/22 Invoice Date Co Lot Lot Address Opt Catt Acct Cat Description Amount 074150977037372 03/04 22 Preacqui Lion Land Costs 12,250.00+ **** TOTAL ''".F.i. 12,250.00 ■ ■ ■ THE ORIGINAL DOCUMENT HAS A WHITE REFLECTIVE WATERMARK ON THE BACK.HOLD AT AN ANGLE TO VIEW.DO NOT CASH IF NOT PRESENT. ,' ' %%1 I ''ItiV - Che?k Numbey 64.1478 ' Pulse Home CorR Ra lteYi hpiv ' 0611' 3350Peachtteedad NE ` Check Date 03/08/22 , Pul „ u MnotbG0A275 1 •I / I 8 f "t, i ' Vf 1,,., sl .' ,; . Void Ater 80 Days I PAY TWELVE THOUSAND TWO HUNDRED FIFTY AND 00/100 DOLLARS 2 $****12,250.00 B Bank of Amenca Customer Connection Atlanta,Dekalb County,GA S TO THE TOWN OF FUQUAY-VARINA M3 (.1{AA.134 N MAIN STREETl ORDER OF FUQUAY-VARINA, NC 27526