NCC215680_FRO Submitted_20211028

U 0 U A Y— VA R a it
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 Carolina Gardens - Phase 11-18
2. Location of land -disturbing activity: Highway/Street Purfoy Road
3. Approximate date land -disturbing activity will commence: Spring 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 41.0
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Raughley/Pulte Group E-mail Address Chris,[e-mail]
Telephone [phone] Cell # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
_Pulte Home Company, LLC [e-mail]
Name E-mail Address
1225 Crescent Green Dr. Suite 250
Current Mailing Address
Same
Current Street Address
Cary, NC, 27518 Same
City State Zip City State Zip
8. Deed Book No. 017377 Page No. 00645 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):
Chris Raughley [e-mail]
Name E-mail Address
1225 Crescent Green Dr. Suite 250
Current Mailing Address
Cary, NC, 27518
City State Zip
Telephone [phone]
Same
Current Street Address
Same
City State Zip
Town of Fuquay-Varina - 401 Old Honeycutt Road, Fuquay-Varina, NC 27526
[phone] = 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
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
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:
Pulte Nome Company, LLC [e-mail]
Name E-mail Address
1225 Crescent Green Dr. Suite 250 Same
Current Mailing Address Current Street Address
Cary, NC, 27518 Same
City State Zip City State Zip
Telephone [phone]
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 Raughley VP Land Development
Type or print nnaame Title or Authority r
Signature U V Date
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I, M&I r S*l �2W-GH rt'FL , a Notary Public of the County of We 14t
State of North Carolina, hereby certify that S h f i S 12—ch't11�1 1appeared personally
before me this day and being duly sworn acknowledged that the ab a form As executed by him.
Witness my hand and notarial seal, this _day of UA2irtA N r 20 Z
S ME
Notary
Seal _ �;'�4-TARY 0-7 12 C_
` My Eomrrlssion expires
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