NCC216982_FRO Submitted_20211216

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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 Kingston Wood — Watermark Lots
2. Location of land -disturbing activity: Highway/Street Fleming Road
3. Approximate date land -disturbing activity will commence: September 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): 3.6 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brady Rufenacht E-mail Address bradyCa watermarkhomesnc.com
Telephone [phone] Cell # 910 237 1472
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Watermark Homes. Inc. [e-mail]
Name E-mail Address
196 Annette Drive 196 Annette Drive
Current Mailing Address Current Street Address
Benson, NC 27504 Benson, NC 27504
City, State, Zip City, State, Zip
8. Deed Book No. 18519, 18047, 18780 Page No. 2736, 2107, 1540 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):
Watermark Homes Inc. brady watermarkhomesnc.com
Name E-mail Address
196 Annette Drive 196 Annette Drive
Current Mailing Address Current Street Address
Benson NC 27504 Benson, NC 27504
City, State, Zip City, State, Zip
Telephone [phone]
Town of Fuquay-Varina H 401 Old Honeycutt Road, Fuquay-Varina, NC 27526 E
[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:
Tim Matthews czitina(o).aol.com
Name E-mail Address
407 North Judd Parkway 407 North Judd Parkway
Current Mailing Address Current Street Address
Fuquay-Varina, NC 27526 Fuguay-Varina, NC 27526
City, State, Zip City, State, Zip
Telephone [phone]
(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.
Brady Rufenacht
Type or print name Title or Authority
ol'ignatu_rg`
State of NQah Carolina, hereby certify that
before me this day and being duly sworn
Witness my hand and notarial seal, this
a
day
President, Watermark Homes, Inc.
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Date
of the County of
UY -'appeared personally
executed by him.
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