NCC221088_FRO Submitted_20220322

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 Madison Park Apartments
2. Location of land -disturbing activity: Highway/Street Between US 401 and Ransdell Road
3. Approximate date land -disturbing activity will commence: February 2022
4. Type of development (residential, commercial, industrial, institutional,etc.):--- Apartments
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 9.9 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
, Name Steven Whitworth E-mail Address [e-mail]
Xelephohe _(980) 326-2246 Cell #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
VCP FV LLC and VCP FV 11 LLC [e-mail]
Name E-mail Address
2110 Powers Ferry Road, Suite 150 2110 Powers Fe rry Road Suite 150
Current Mailing Address Current Street Address
Atlanta, GA 30339 Atlanta, GA 30339
City State Zip City State Zip
8. Deed Book No. 018381 Page No. 02291 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):
VCP FV LLC and VCP FV 11 LLC [e-mail]
Name E-mail Address
2110 Powers Ferry Road, Suite 150 2110 Powers Ferry Road, Suite 150
Current Mailing Address Current Street Address
Atlanta, GA 30339 Atlanta, GA 30339
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina = 401 Old Honeycutt Road, Fuquay-Varina, NC 27526
[phone] E fuquay-vaJna.org

2. (a) if the Financially Responsible Party is n j a re fi t n1,Wtil e CZ,gty, 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:
Robbie Bell [e-mail]
Name E-mail Address
6310 Chapel Hill Road Suite 250 6310 Chapel Hill Road, Suite 250
Current Mailing Address Current Street Address
Raleigh, NC 27607 Ralei h NC 27607
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:
Trace McCreary
Name
trace,[e-mail]
E-mail Address
2110 Powers Ferry Road, Suite 150 2110 Powers Ferry Road, Suite 150
Current Mailing Address Current Street Address
Atlanta, GA 30339
City State Zip
Atlanta, GA 30339
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.
--ace McCreary, Manager
Type or print name Title or Authority
-- _-� 1 /24/2022
Signature Date
1, I iV) � aLfc(a a Notary Public of the County of
State of , hereby certify that e C appeared personally
before mr id being duty sworn acknowledged that the above form was executed by him,
ih_
day of
Witness my hand and notarial seal, this —tanv 20 Z
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