NCC242904_FRO Submitted_20240919

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 Parker Station Plaza
2. Location of land-disturbing activity: Highway/Street 920 N. Main Street
3. Approximate date land-disturbing activity will commence: 10/2022
4. Type of development (residential, commercial, industrial, institutional,etc.).Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas):2.67 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tom Spaulding, PE E-mail Address [e-mail]
Telephone [phone] Cell # n/a
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Parker Station, LLC [e-mail]
Name E-mail Address
5318 Burning Oak Ct same
Current Mailing Address Current Street Address
Raleigh, NC 27606 Same
City State Zip City State Zip
8. Deed Book No. 18102 Page No. 147 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):
Parker Station, LLC tom©spaulding-group.com
Name E-mail Address
5318 Burning Oak Ct Same
Current Mailing Address Current Street Address
Raleigh, NC 27606 Same
City State Zip City State Zip
Telephone [phone]
Town of Fuquay Vanna = 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.
Tom Spaulding- Managing Member Parker Station, LLC
Type or print narn 11(49r Authority
06/03/2022
Signature Date
I, cJ NrA) 1 to a,.n C 0.— \ , a Notary Public of the County of Wake
State of North Carolina, hereby certify that Tc::r" Sea.LA-I-G nq_. appeared personally
before me this day and being duly sworn acknowledged that the above fdr)n was executed by him.
Witness my hand and notarial seal, this day of J �, , 2022
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Notary
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