NCC231403_FRO Submitted (2)_20230511

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FUQUA"—VAR e 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 &4 Subdivision
2. Location of land-disturbing activity: Highway/Street Rogers 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): 49 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Scott Cobb E-mail Address [e-mail]
Telephone Cell# [phone]
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Pulte Home Company, LLC Chris.Raughley(a�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):
At 4OAtt COM?a„4 LLC L1nr:t. ra ink av14-c . caw\
Name E-mail Address
I225 Grtsc_c�k C -u.. Or.
Current Mailing Address Current Street Address
Cow NC 27S 1‘
City State Z/p City State Zip
Telephone _l I Ck 8(k 11 We
Town of Fuquay-Varina E 401 Old Honeycutt Road, Fuquay-Varina, NC 27526
[phone] 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.
Chris,RtghleyvVP of Land Development
Type or print name 1'itWor Authority
CJt,v Ra.„a/� 3 • 7 • 2.2.
Signature 0 V Date
I, /Vl tti Sh s✓VLL.4zrvt2 , a Notary Public of the County of WA key
State of North Carolina, hereby certify that cAi v C (G1i(..may appeared personally
before me this day and being duly sworn acknowledged that the bove fefm was executed by him.
Witness my hand and notarial seal, this 'I day of /V ...-t VL- , 20
,,`, SMET'q ,',�'� Notary
5P .
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Seal =z% ,01 A y
My commission expires
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IPulteGroup 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
074411072689337 03/04/22 comm-8067 Providence Oaks(806 1,750.00+
**** TOTAL *8••`* 1,750.00
■ ■ ■
THE ORIGINAL DOCUMENT HAS A WHITE REFLECTIVE WATERMARK ON THE BACK.HOLD AT AN ANGLE TO VIEW DO NOT CASH IF NOT PRESENT.
gyI
1 ! 'I=-"isiQ Check Number
a 1 7tP
s
f30PHoaGe P4a,l111, rytv , p Check pate 03/08/22-
RPuLteGr 'uni�;Aa taG 0A2751„ f"',i '�i, t ,..
VoldAfter j 80 Days I
PAY
ONE THOUSAND SEVEN HUNDRED FIFTY AND 00/100 DOLLARS **** 8
$ 1,750.00 8
3
Bank of America $
Customer Connection
Atlanta,Dekalb County GA 8
TO THE TOWN OF FUQUAY-VARINA i
134 N MAIN STREET I
ORDER OF FUQUAY-VARINA, NC 27526