NCC216889_FRO Submitted_20211213

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north corolino
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 Crossfit Shoofly
TOFV Project #SP-2018-06
2. Location of land -disturbing activity: Highway/Street 810 Durham Street & 304 E Main Street
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): Exercise Facility, Office, Retail
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 1.13 Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John T. Beaird
E-mail Address [e-mail]
Telephone [phone] Cell # 919-441-8100
7. Landowner(s) of Record (attach accompanied page to list additional owners):
BEAIRD INVESTMENT GROUP LLC [e-mail]
Name E-mail Address
5208 THISTLEBY RD SAME
Current Mailing Address Current Street Address
FUQUAY VARINA, INC 27526-9097 SAME
City State Zip City State Zip
8. Deed Book No. 018006 Page No. 00749 - 00750 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):
BEAIRD INVESTMENT GROUP LLC [e-mail]
Name E-mail Address
5208 THISTLEBY RD SAME
Current Mailing Address Current Street Address
FUQUAY VARINA, INC 27526-9097 SAME
City State Zip City State Zip
Telephone
919-441-8100
Town of Fuquay-Varina E 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
Name
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
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:
Beaird Investment Group, LLC -Registered Agent: John T. Beaird [e-mail]
Name E-mail Address
5208 Thisleby Rd Same
Current Mailing Address Current Street Address
Fuquay Varina, NC 27526-9097 Same
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.
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a Notary Public of the County ofLv(�
State of North Carolina, hereby certify that J (>M 1_ (<j appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this '-q V-day of Yt 6 20
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