NCC216397_FRO Submitted_20211117

r- UQUAY VAR s NA
Upd,, W north corolino
Financial Responsibility/Ownership Form SPCA
See TOW LDO, Section W1407 SOIL EROSION & SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Project Name_ = V is _to r
2. Location of land -disturbing activity:
d C1 tilo r w sfy'et'
3. Approximate date land -disturbing activity will commence: -
4. Type of development (residential, commercial, industrial, institutional,etc.): r
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas):
6. Person to contact should if
and sediment control issues arise during land -disturbing activity:
Name 6 11 0 y' le s g+
o i 1 ..` E-mail Address_if L I' t Cp kn b la'# CC,
Telephone gjq,- 000 — 4b63 Cell # q/9- -tEZZ_ 22a 39 q - 0 97 7
7. Landowner(s) of Record (attach accompanied page to list additional owners):
/1 + J +
_A_y a - Gi, L¢,r la, AR J= ���h�c.—1�1�tr1c Q C�y;alart�rPr+�.��rr�
Name E-mail Address
Current Mailing Addre
s�aJ-Varhr�, G_ 2757- 6
City .Nate Lip
Current Street Address
City State Zip
8. Deed Book No. J16 / 9 S Page No. 00 _ 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 Informr�ation):
Ink � , ~ , 5
Name ( �~ E-mail Address
Current Mailing Address Current Street Address
TaLa, L 4G 27607 s
City State Zip City State Zip
Telephone // c - 5 -1 o
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:
Brian Denisar, Chief Executive Officer [e-mail]
Name E-mail Address
600 Germantown Rd.
Current Mailing Address Current Street Address
Raleigh NC 27607
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.
Charles Howe, Vice President
Type
Authority
Date
I. t' , a Notary Public of the County of ' daKe
State of No h Carolina, hereby certify that Ck�Zrlf_s }- vine— appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of _j k4n�02r , 20
cY B. oFN%,,h,
Seal • N
p�e� Rr X
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My commission expires