NCC241673_FRO Submitted_20240531

ArK
FUQU,AY-VAR ! 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 Vinci
2. Location of land-disturbing activity: Highway/Street 6524 Burt Road, Holly Springs, NC
3. Approximate date land-disturbing activity will commence: May 2024
4. Type of development(residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): 3.28
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeff White E-mail Address [e-mail]
Telephone Cell# 919.422.5741
7. Landowner(s) of Record (attach accompanied page to list additional owners):
GHD-Vinci LLC [e-mail]
Name E-mail Address
1330 Sunday Drive, Suite 105 same
Current Mailing Address Current Street Address
Raleigh, NC 27607-5196 same
City State Zip City State Zip
8. Deed Book No, 019526 Page No. 01755 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):
GHD -Vinci LLC [e-mail]
Name E-mail Address
1330 Sunday Drive, Suite 105 same
Current Mailing Address Current Street Address
Raleigh, NC 27607-5196 same
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina = 134 N Main Street, 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:
Jeff White [e-mail]
Name E-mail Address
1330 Sunday Drive, Suite 105 1330 Sunday Drive, Suite 105
Current Mailing Address Current Street Address
Raleigh, NC 27607-5196 Raleigh, NC 27607-5196
City State Zip City State Zip
Telephone [phone]
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.
Jeff White, Chief Operating Officer
Il
p- •, print na a itle or Authority
—tt-Z4
Sign.' u e Date
I, J 0141 e&,^CI , a Notary Public of the County of Likte
State of North Carolina, hereby certify that QT1,tt}}A 41/1+k appeared personally
before me this day and being duly sworn ac owle�ged tI'i t the above form was executed by him.
Witness my hand and notarial seal,this Vl day of `l , 204
.... 6 - N_ . ,04 i ,,, Notary
Seal =�'��\ '^�°N , III k er7
NOTARY My commission expires
PUBLIC
4,s ti G
2
�, I:.;Jery 11, ° '. z.•1'
C N ,
20221201