NCC240939_FRO Submitted_20240402

r QUAY-VA P.1! NA
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 Primrose School
2.Location of land-disturbing activity: Highway/Street Attain Street
3.Approximate date land-disturbing activity will commence:
4.Type of development(residential,commercial,industrial, institutional,etc.):Institutional
5.Total acreage disturbed or uncovered(including off-site utilities and borrow/waste areas):1.67 AC.
6.Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ted Tillman E-mail Address [e-mail]
Telephone[phone] Cell#[phone]
7.Landowner(s)of Record(attach accompanied page to list additional owners):
David W.Ball,Michele B.Ball
Name E-mail Address
I0305 Sauls Road
Current Mailing Address Current Street Address
Raleigh,NC 24603
City State Zip City State Zip
8.Deed Book No.19402 Page No.1718 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):
EAtAkAV CWA 4H tCy cw Auk bt-aR.'/ e mitoSirWER-11Ait- wF
Name E-mail Address
-7/ Zi* 0-1 i sz'y S 1?ct itJts i 5 A a---
Current Mailing Address Current Street Address
m(Ly N Z1 51 9
City State Zip City State Zip
43
Telephone q i q -
Town of Fuquay-Varina=134 N Main Street,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.
C-� Ati►2Av GNgt�o��y
Type or print nee Title or Authority
'ara /
Signature Date
I, Ph,I i p tip((itA,si. ,a Notary Public of the County of (AA
State of North Carolina, hereby certify that (q/, C d')(-J appeared personally
before me this day and being duly sworn acknowledged that the abode form was executed by him.
Witness my hand and notarial seal,this /2- day of De co,lo ,20 2 3
mown 4 73��� / �l,''�' HALy, l
�pTA/it •y q2 Notary
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Seal /° I 0-Z2
My commission expires
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Arnmitoll
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20221201