NCC215346_FRO Submitted_20211005

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Financial Responsibility/Ownership Form SPCA
See TOFU LDO, Section §9-1407 SOIL EROSION & SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Project Name Lane Professional Park
2. Location of land -disturbing activity: Highway/Street NC Hwy 55/01d Powell Road
3. Approximate date land -disturbing activity will commence. Fall 2020
4. Type of development (residential, commercial, industrial, institutional, etc.) Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 6.0 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Perry Truelove _ E-mail Address er ruelove lanedds.com
Telephone [phone] Ext.21 Cell # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
1830 N. Broad Street, LLC c/p Perry Truelove [e-mail]
Name E-mail Address
15 Rawls Road Suite 100
Current Mailing Address
Anaier. NC 27501
City State Zip
Rawls Road. Suite 100
Current Street Address
Angier, NC 27501
City State Zip
8. Deed Book No. 16329 Page No. 1137 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):
1830 N. Broad Street, LLC c/p Perry Truelove _ er ruelove lanedds.com
Name E-mail Address
15 Rawls Road Suite 100 15 Rawls Road Suite 100
Current Mailing Address Current Street Address
Angier. NC 27501 Angier, NC 27501
City State Zip City State Zip
Telephone [phone] Ext.2
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A
(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:
Perry Truelove _ [e-mail]
lan_edds.com
Name E-mail Address
15 Rawls Road Suite 100 15 Rawls Road Suite 1
Current Mailing Address Current Street Address
Angier NC 27501 Angier. NC 27501
City State Zip City State Zip
Telephone [phone] Ext.21
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.
Pew-r,4 7-r!4e Io J `. C F b
Type or e i or Authority
Signature Date
1, 3 WNXRL NI rA a Notary Public of the County of �
State of North Carolina, hereby certify that '?CVrj koi/-L appeared personally
before me this day and being duly sworn acknowledgbd that the above form was executed by him.
Witness my hand and notarial seal, this Tlt''day of 20 1A
Q%Ik� �ITrn"'Q_
Noipry
JULIE M BYRD
Seal WakO Counf�,' Nor�Carolina - :al �y2�
Y Commies#an Exp#res My co mission Expires
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