NCC231622_FRO Submitted_20230525

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Finn dad Responsibility/Ownership Form SPCA
See TOF\/ LDO,Section§9-1407 SOIL EROSION &.SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
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1. Project Name L- 7 � ry
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2. Location of land-disturbing activity: Highway/Street ( (;rlrlc5>,A 1S ( If.4_e
3. Approximate date land-disturbing activity will commence: b\t\ a a:3
4. Type of development (residential, commercial, industrial, institutional,etc.): ( ,F n,E `ic�J�
5. Total acreage disturbed or uncovered (including off-site utilities and bon-ow/waste areas): .) .4 0
6. Person to contact should erosion and`sediment control issues arise during land-disturbing activity:
Name ��- e�-,'NiM ,r� k , t!f�itIA<( E-mail Address CA---HAQ—C,rt 9 CV )Gtrd,Q,c
Telephone
1cr .. -0 775 Cell #
7. Landowner(s) of Record (attach accompanied page to list additionalowners):��j
Si- 1 -4-14,(4 s f u p F� , ' , si-1/2 �✓1 (C r VAC/�(ck l �i17 4 LC�Y Ir V\9— C t(C C�L2�r yrt/1
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
8. Deed Book NoO(s 7c 3 Page No.` _ �� 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):
cC 1Jt.NA 16 S L c C-4-1--ks2x;
Name E-mail Address
Current Mailing Address-) Current Street Address
City Stat Zip City State Zip
Telephone C( ( --0`7 /S
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:
Town of Fuquay-Varina E 134 N Main Street,Fuquay-Varina,NC 27526
[phone] E fuquay-varina.org

Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name,
att:acl-r 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:
L-,'-v1J\ l;" IC I L",-J O C C (A.)6 .'f c-A Jl/ i ( iz-1
Name (� �a
p i E-mail Address
° l_�l�r(L✓�`'�Thin EJ c r t,/- , 1 DS
Current Mailing Address Current Street Address
Lam , C 1
City State ip City State Zip
Telephone C( r\r (� —6-7--6--
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.
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Type or print name Title or Authority
;„ l . P'13/23
Signature Date
I, V lek ie S. � cK)5 , a Notary Public of the County of liJake
State of North Carolina, hereby certify that Bertm» X. GJard appeared personally
before me this day and being duly sworn acknowled uged that the above form was executed by him.
Witness my hand and notarial seal, this �-{- day of (Y)ati , 20 23
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:�► 4.• Notary
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Seal S j 23 Z(o
ar * * My commission expires
611.0
20221201