NCC231887_FRO Submitted_20230628

FUQUAY-\ AR I A
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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 Kensley Grove
2. Location of land-disturbing activity: Highway/Street Bevis Marks Drive
3.Approximate date land-disturbing activity will commence: March 2023
4. Type of development(residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): 10.4 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mitch Barron E-mail Address [e-mail]
Telephone [phone] x4029 Cell# 919-225-1078
7. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached See attached
Name E-mail Address
See attached See attached
Current Mailing Address Current Street Address
See attached See attached
City State Zip City State Zip
8. Deed Book No. See attached Page No. See attached 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):
DRB Group [e-mail]
Name E-mail Address
3000 RDU Center Drive-Suite 202 3000 RDU Center Drive-Suite 202
Current Mailing Address Current Street Address
Morrisville, NC 27560 Morrisville, NC 27560
City State Zip City State Zip
Telephone [phone] x4001
Town of Fuquay-Varina.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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A o N/A
City State Zip City State Zip
Telephone N/A
(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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A
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.
Ric Rojas Division President
Type or pri t Ili Title or Authority
10- 4-ZZ
Signature Date
I, AvvtarwACk. � , a Notary Public of the County of W C4...k
State of North Carolina, hereby certify that -R i C.- 1R0 a-S appeared personally
before me this day and being duly sworn acknowledged thaYthe above form was executed by him.
Witness my hand and notarial seal,this (p lay of Qc-'rob2.r , 20 22-
AMANDA L MART.INEZ Notary
Notary Public, North :;arolina
Seal Wake County '6 - /3 - ZO 2[
My Commission Expires August 13,2024 My commission expires