NCC216741_FRO Submitted_20220103

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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 FOREST BLUFF ESTATES
2. Location of land -disturbing activity: Highway/Street
2507 N. Main Street
3. Approximate date land -disturbing activity will commence: August/September 2019`
4. Type of development (residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 11.60 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name JWM-FBE, LLC
Telephone
919-614-2909
E-mail Address [e-mail]
Cell # 919-614-2909
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Lynwood & Cassandra Daniel
Name
2601 N. Main Street
Current Mailing Address
Fuquay-Varina, NC 27526
City State Zip
8. Deed Book No. 016411
E-mail Address
same
Current Street Address
same
City State Zip
Page No. 00303 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):
JWM-FBE, LLC [e-mail]
Name E-mail Address
6600 Brookshire Drive same
Current Mailing Address Current Street Address
Fuquay-Varina, NC 27526 same
City State Zip City State Zip
Telephone
919-614-2909
Town of Fuquay-Varina E 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:
Thurston Debnam
Name
4601 Six Forks Road Suite 400
Current Mailing Address
Raleigh, NC 27609
City State Zip
E-mail Address
Same as mailing
Current Street Address
Same as mailing
City State Zip
Telephone '110l,- ZSD-?zW
(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
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Wayne Massengill - Owner �� [
Type or print name Title or A rity
Signature Date
I.C1c7 a Notary Public of the County of.�
State of North Carolina, here certify that ,ti [ appeared personally
before me this day and being duly sworn ack6owledgbd that the above lorm was executed by him.
Witness my hand and notarial seal, this 2=jL day of i
ANGELA MORGAN Notary
Seal Notary Public
Harnett Co., North Carolina My commission expires
My Commission Expires Feb. 28, 2022