NCC232081_FRO Submitted_20230711

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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 Broadwell Estates
2. Location of land-disturbing activity: Highway/Street 751 Coley Farm Road
3.Approximate date land-disturbing activity will commence: 8/1/Z3
4.Type of development(residential, commercial, industrial, institutional,etc.):Residential !!��
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): I4 70
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Andy Crawford E-mail Address [e-mail]
Telephone [phone] Cell# 9/9— *Z7- 2 96 2.
7. Landowner(s)of Record (attach accompanied page to list additional owners): Aytf a c`iem' 14s4 p4 e et FRO.
G fY1 8, 0o /we.//, LLc D�ack5041.ecrib�Ql�"eY'✓'ec. . co•�
Name E-mail Address J
/H0 V/j/via Qr/ve SAME
Current Mailing Address Current Street Address
Foy� WehrA/4 p foti PA 15 0 3'/
City State Zip 018.54 1 --- 01678-0168o City State Zip
8. Deed Book No.0/B561 'rPage No.e/6 76 -047 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):
Ectsfc,Jocd — Akes of 142t C,C,�.. [e-mail]
Name E-mail Address
7/0/ Cr e ee yi•,o o,- ,Pd, //.S ��/1/,E
Current Mailing Address Current Street Address
Raleigh, NC 2 7‘/3
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina E 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 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,
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip 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.
Andy Crawford Vice President
Type or print name Title or Authority
G�G i//s/�3
Sign e Date
I, O-i\-t �,�,ICii " as Notary Public of the bounty of WCLI
State of North Caro a, hereby certify that J\f 166-\ ( (a.LL.1.J'b(C, appeared personally
before me this day and being duly sworn acknowledge hat the above form was executed by him.
Witness my hand and notarial seal, this 15 day of (D , 20 93
Notary
In _ )
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(9
Seal
Myc 14/ ryp�6 � My commission expires