NCC216527_FRO Submitted_20211122

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Financial Responsibility/Ownership Form SPCA
See TOFV LIDO, Section §9-1407 SOIL EROSION & SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Project Name Meadowbrook Subdivision Phase 3 Erosion Control
2. Location of land -disturbing activity: Highway/Street 6600 S. NC 55 Highway
3. Approximate date land -disturbing activity will commence: June 2021
4. Type of development (residential, commercial, industrial, institutional,etc.): Single Family Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 19.7
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Pete Sullivan E-mail Address [e-mail]
Telephone
Cell # 919.427.0618
7. Landowner(s) of Record (attach accompanied page to list additional owners):
BCELD Meadowbrook LLC
Name
402 N Fourth Street
Current Mailing Address
_Baton Rouge, LA 70802
City State Zip
8. Deed Book No. 16901
E-mail Address
Current Street Address
City State Zip
Page No. 2458 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):
BCELD Meadowbrook LLC
Name E-mail Address
402 N Fourth Street
Current Mailing Address Current Street Address
Baton Rouge, LA 70802
City State Zip City State Zip
Telephone__ 225.338.6120
Town of Fuquay-Varina - 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:
Ethan Brodnick [e-mail]
Name E-mail Address
509 Pylon Drive
Current Mailing Address Current Street Address
Raleigh, NC 27606
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
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
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.
Todd Wague ack - Au orized Representative
Type or print e Title o uthority
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Signature Date
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1, 1�1 �� ow�Sl�
a Notary Public of th unty of � S '� �-,Gt� Cr► ��
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn ac nnowledged that the bove f rm was executed by him.
Witness my hand and notarial seal, this L ' day of �,1,V,e/y , 20'Z-\
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