NCC223704_FRO Submitted_20221031

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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 WakeMed MOB Fu ua -Varina
2. Location of land -disturbing activity: Highway/Street 2400 N Main Street Fu ua -Varina NC 27526
3. Approximate date land -disturbing activity will commence: 05/27/22
4. Type of development (residential, commercial, industrial, institutional, etc.): Medical Office Buildino
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 13 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Roy Lorenzen E-mail Address_ rorenzen([e-mail]
Telephone 919.830,8750 Cell # 919.866.4813
7. Landowner(s) of Record (attach accompanied page to list additional owners):
WakeMed Property Services tcavender wakemed.or
Name E-mail Address
3000 New Bern Ave 3000 New Bern Ave
Current Mailing Address Current Street Address
Raleigh, NC 27610 Raleigh, NC 27610
City State Zip City State Zip
8. Deed Book No. BM2002 Page No. 00289 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):
WakeMed Property Services tcavender wakemed.or
Name E-mail Address
3000 New Bern Avenue 3128 Smoketree Court
Current Mailing Address Current Street Address
Raleigh, C 27610-1231 Raleigh, NC 27604-1014
City State Zip City State Zip
Telephone T:919.350.8098-. C:919.796.9942
Town of Fuquay-Varina - 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:
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
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. t l
Ty or print name Title or Authority
Signature
Date
a Notary Public of the County of W 7-
State of North Carolina, hereby certify that e-:AV :r,_g- tZ- 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 21 day of 1� z Nva+2 20 Z�-
MABEL CUBILLOS
NOTARY PUBLIC
Seal WAKE COUNTY, NC
1
otary
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