NCC216852_FRO Submitted_20211210

Im
notillcolotillo
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 South Lakes SF-8 AR- 1
2. Location of land -disturbing activity: Highway/Street Fuguay-Varina Parkway
3. Approximate date land -disturbing activity will commence: 12/14/21
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 25.6
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Justin Heaton E-mail Address iustinheatonCEO hhomes. com
Telephone [phone] Cell # 732-644-0565
7. Landowner(s) of Record (attach accompanied page to list additional owners):
DFC South Lakes LLC ch. swan c(DWcapitalmanagement.com
Name E-mail Address
14701 Philips Hwy, Suite 300 14701 Philips Hwy, Suite 300
Current Mailing Address Current Street Address
Jacksonville FL 32256 Jacksonville FL 32256
City State Zip City State Zip
8. Deed Book No._ 014212 Page No. 02279 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):
H&H Constructors of Fayetteville, LLC iustinheato (@hhhomes.com
Name E-mail Address
7200 Falls Of Neuse Road Suite 202 Raleigh NC 27615 7200 Falls Of Neuse Road Suite 202 Raleigh NC 27615
Current Mailing Address
Current Street Address
Raleigh, INC 27615 Raleigh, NC27615
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina E 401 Old Honeycutt Road, Fuquay-Varina, NC 27526
[phone] H 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
f-:1'iFi1 G :['1?
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:
Name
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
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.
Ty e or print name Title or Authority
ignature Date
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I, a Notary Public of the County of WCL(-'Q
State of North Carolina, hereby certify that )�A`� �nQ.(kd 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 6 k day of 20j_
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t° My commission expires
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