NCC231859_FRO Submitted_20230614

FUQUAY-\/AR 1 NA
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 gig Storaoe 411top-Needvmore, LLC
2. Location of land-disturbing activity: Highway/Street 5744}{i111-op Needtmore.oad
3. Approximate date land-disturbing activity will commence: Jm0e 2023
4. Type of development (residential, commercial, industrial, institutional,etc.): Cotmtmercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): 4.52 ac (5 ac)
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Wlark Wlomser E-mail Address wiarkwlomserZrevltstack1omse.cowl
Telephone 51S.S5q.g475 Cell# 513.5560475
7. Landowner(s) of Record (attach accompanied page to list additional owners):
q1 1 Storage}Iilltop.-Needtmore, LLC rol�ertZoaviderdev.cotm
Name E-mail Address
2310 S. Miami 13omlevard Smite 235 2310 S. Wliatmi l3omlevard Smite 235
Current Mailing Address Current Street Address
1Dmrliiatm, NC 27703 Pmrltiavn, NC 27703
City State Zip City State Zip
8. Deed Book No. 1'3375 Page No. 15611 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):
e11q Storage 41ltolD-Needvnore, tmarkwlomserZrevltstackliomse.cowl
le E-mail Address
2310 S. lMiatmi 13omlevard Smite 235 2310 S. VMiawli 13omlevard Smite 235
Current Mailing Address Current Street Address
Vmrliiatm, NC 27703 DmrlVatm, NC 2.7703
City State Zip City State Zip
Telephone 51S.35e1.g1475
Town of Fuquay-Varina E 401 Old Honeycutt Road, Fuquay-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:
Ccnrry t;t4neerivis romp,'FLU, (Avt(kew Tetty) avid4Zctitrme9.covn
Name E-mail Address
205 Socnt11 Frngtitay AVe&t'i e Saone
Current Mailing Address Current Street Address
Fmgrna9-Varina, NC 2752fp Same
City State Zip City State Zip
Telephone q1q-552-034q
(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:
�aracorp Incorporated
Name E-mail Address
17(0 Wlivie Lake Ct #100 Same
Current Mailing Address Current Street Address
RaleVrt, NC21(915 Wake Comvit4 Saone
City State Zip City State Zip
Telephone ei16i-610e-( 726i
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.
() A C
Typ r p 'nt na e Title or hority
6 - 03 -,2023
Signat e Date
I, tai_`M,M 20 d -Y , a Notary Public of the County of �Y 0. Y�
State of North Cdrolina, hereby certify that --\- ob. .vr'k L • SI,rw-v�Y- - 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 \? day of��Y-,�� , 20
r--
Tammy Rosander a
NOTARY PUBLIC
Sec I Wake County ' l QC)North Carolina
My CommissionExp4es 11/18/2026 My commission expires
20221201