NCC230304_FRO Submitted_20230202

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Financial Responsibility/Ownership Form SPCA
See TOFU LDO, Section §9-1407 SOIL EROSION & SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Project Name Preserves at Holland Single Family Lot EC Plan - Envision Homes Lots
2. Location of land -disturbing activity: Highway/Street Shiloh Hills Drive & Lily Claire lane
3. Approximate date land -disturbing activity will commence: Winter 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 6.90 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity -
Name Larry Michael Mick E-mail Address mick(cD_envisionhomesnc.com
Telephone [phone]
Cell # 919.414.4780
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Trinity Brownstones. LLC
Name
[e-mail]
E-mail Address
4441 Six Forks Road Suite 106-117 4441 Six Forks Road Suite 106-117
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleiah NC 27609
City State Zip City State Zip
8. Deed Book No 018724
Page No. 2489 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):
Trinity Brownstones, LLC [e-mail]
Name E-mail Address
4441 Six Forks Road Suite 106-117 4441 Six Forks Road Suite 106-117
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varna HE 401 Old Honeycutt Road Fuquay-Varna NC 27526 Ez
(9191 552-1400 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
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.
Larry Michael (Mick)
Type or print name Title or Authority
Managing Member
Z2,
Signature Date
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i, ' 1 e� lr ,45D v1 , a Notary Public of the Coun of
State of North Carolina, hereby certify that ►�Vw1 appeared personally
before me this day and being duly sworn acknowledge thattl�Le above form was executed by him.
Witness my hand and notarial seal, this day of 20 a—�--
P_ dA� ,a la-l� Cc X-L'
ANNALEE RICHARDSON Notary
Notary Public
North Carolina
Seal 3 Wake County
My commission expires