NCC223665_FRO Submitted_20221026

FU0UA- A/A- R 1, NA
ii±irlh c(J1fdirui
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 Lakestone Tract-5 Mixed Use
2. Location of land -disturbing activity: Highway/Street Laieestone Commons Ave, US 401
3. Approximate date land -disturbing activity will commence:
July 1 - Oct 1
4. Type of development (residential, commercial, industrial, institutional, etc.): Mixed Use Residential
5. Total acreage disturbed or uncovered (including off -site: utilities and borrow/waste areas): 6.23 ac
5. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
O- r� Name S 4P I fl E-mail Address (/ ter. Si��- Sfi •ors. �c�.+�
Telephone l C7 cF� `� 3 3 Cell # 10 - 3 - U 3
7. Landowner(s) of Record (attach accompanied page to list additional owners):
C�-S �CJ ✓� .-+-z r .� C " c✓� C/ _� ter- / r-r i / � c
Name E-mail Address
Current Mailing Address Current Street Address
City Stat6 Zip City State Zip
8. Deed Book No. 9671 Page No. 2727-2730
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):
Ca-. \ C Ca-" ✓Y! r rC ���J/J�r-/�r3+ �k at 14 - S42,20 . Ccl+ t
Name E-mail Address
Current Mailing Address J Current Street Address
e Y v.r/r 3 v3
City StatJ Zip City State Zip
Telephone
Town of 1=uquay-Varina = 401 Old Honoycutt Road, F'uquay-Varina, NC 27526
[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:
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
ands et address of the Registered Agent: r
U -E /-,� L7 _�— � e z/,. I —
Name l J E-mall Address V '
n_4 TG "_A__
Current Mailing Address Current Street Address
-city St4 Zip �f `,City State Zip
Telephone 'FtL7- 3U -- -2303 Tto -9Y. 3,-�33 W
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.
6;)
- "I�rL,
Type or print ri 0- le or Authority
zeG�z/
nnafI Wia Date
wl t/LL (' la CGPGO45 , a Notary Public of the County of 1"
State of North Carolina, hereby certify that `ileAr1oV(P_AeU appeared personally
before me this day and being duly sworn acknowledged at the above form was executed by him.
Witness my hand and notarial seal, this l 9n day of VL GSM 20 S i
_ , Notary
Seal ��,��01ARr;N,
n' 0 UB 0C, 'z
ND
My commission expires