NCC242461_FRO Submitted_20240814

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 4ir r'ii.A'4 4r' " .1-OT4 I -IL
2. Location of land-disturbing activity: Highway/Street OWVW-AAABL E Lk 7gj►.kcg 4-004 g P bC to z r
3.Approximate date land-disturbing activity will commence: 01 JuiLE 1411-4
4. Type of development(residential, commercial, industrial, institutional,etc.): 4IPrg T l---
!{.ers WWI'5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): 4.L 8` ! 1.1 I.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name -PI(4 414f I7A4 44 E-mail Address rsbtrwuvl0 tie wlkow►!j nt .toA4
Telephone (9la) +Z1- - IS 3 S Cell# (' ) +i-?- 2638
7. Landowner(s)of Record (attach accompanied page to list additional owners):
f�1' `rU.bAS P L PE4FIArMiMr i ilt 4t+144- t Wttievoto444-rdt_410h .Le.4
Name E-mail Address
Current Mailing Address Current Street Address
VusW , nit 213 3 3/"--- ,,,,,,--
City State Zip City State Zip
�Mtio $ — .l-i'ts r40-r �fEr
8. Deed Book No. I Page No. 00 2�D Provide a copy of the most current deed. gEGogoE2
Part B.
1. Person(s) or firms)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all
responsible parties on an attached sheet. Include requested Information):
NSW I+tNIW Ir4L. LLL o1.1 Ile 0 ,114.404)6W es."C.. I0M
Name E-►nail Address
MI Jadfs n'z M-1.-Ia 14. 6,- lb I
Current Mailing Address Current Street Address
1- ood4 , kit DI Is 0
City State Zip City State Zip
Telephone (i ) +i i - 'i1 tf
Town of Fuquay-Varina E 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:
- Richard Van Tassel II [e-mail]
Name E-mail Address
—m 1611 Jones Franklin Rd #101 SAME
Current Mailing Address Current Street Address
Raleigh, NC 27606 SAME
City State Zip City State Zip
Telephone `--- 919-239-4747 x102
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.
VA L-L..g4 TO Ui -- , Mst,.4 A b E14—
Type o int name Title or Authority
�_ —, Ole nAAT 102.¢-
Signature Date
I, r Ma 14, ci 1.Pf o i , a Notary Public of the County of w4`-k-e....-
State of North Carolina, hereby certify that aticks 1"0 w II< appeared personally
befor me this day and being duly sworn acknowledged that the above form was executed by him.
Witne my hand and notarial seal,this _day of Piny , 20 a 1-1'
MARY K CLIFFORD
NOTARY PUBLIC
I WAKE COUNTY lln GC
Notary (Ilk)
4 STATE OF NORTH CAROLINA `
Seal r . g, .z oa,9
My commission/expires
20221201