NCC231616_FRO Submitted_20230525

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See TOFV LDO,Section§9-1407 SOIL EROSION &SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A. /
'I. Project Name 1 ..)-( —� i F1�lNi � F/vc s
2. Location of land-disturbing activity: Highway/Street ( Vrr/I/1` fa epf e:40_ ((EiLe
3. Approximate date land-disturbing activity will commence: 5 at,w3
4. Type of development (residential, commercial, industrial, institutional,etc.):
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): O •`3-1
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name � Ward(lc f/� E-mail Address (/W241 cL 1,ADa(etc;04 1 Cu i/t/-����i,/,��r�
Telephone 6f� i �I � — -7-75- Cell #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
.Pet( .1.sk'tp (4 I/J(1k) C + r i A 9_ E C/\_) g SCvlCoAi
Name E-mail Address
b(1 ,L C DILF
Current Mailing Address J Current Street Address
City State Zip City State Zip
8. Deed Book No.biC67 '3 Page No Provide 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): p
ITS Yl uric �n �� ll C IC I CF1 �._ �C—kkS2X;V�� lApa rd.S01,
Name E-mail Address
\000 bA,rr ii\ 1 )(�✓t I 1 DS (A.A
Current Mailing Addressi Current Street Address •
City State'Zip City State Zip
Telephone CI( ( ( L:
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:
Town of Fuquay-Varina-134 N Main Street,Fuquay-Varina,NC 27526
[phone]= fuquay-varina.org

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,
`kach a copy of the Certificrice of Assumed Name. If the Financially Responsible Party is a Corporation, give name
and
street address of the Registered Agent:
��1 Gem b EilT IC , �, cureA (AJCA f�i�< mil Cool
Name E-mail Address
Current Mailing Address Current Street Address
City State ip City State Zip
Telephone (-�5.-
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 Authority
613/23
Signature Date
I, _WC kie S. "f` , a Notary Public of the County of Wake-
State of North Carolina, hereby certify that 13en``a.M�� 1C• L1iGt_rd appeared personally
before me this day and being duly sworn acknowle' ged that the above form was executed by him.
Witness my hand and notarial seal, this -6-4d day of Mali , 2023
Airfr
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>. Notary
Seal My commission expiresktu COVit
20221201