NCC220938_FRO Submitted_20220302

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F! OUA-\(-I/A R IN A
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 Carolina Gardens - Phase 19-22
2. Location of land -disturbing activity: Highway/Street Purfoy Road
3. Approximate date land -disturbing activity will commence: Fall 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 52.0
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Rau hle IPulte EhwM 14oftt &­1f4 LtE-mail Address. Chris. Raughley@PulteGroup-com
Telephone [phone]
Cell # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners)
Pulte Home Company, LLC [e-mail]
Name E-mail Address
1225 Crescent Green Dr. Suite 250 Same
Current Mailing Address Current Street Address
Cary, NC, 27518 Same
City State up City State Zip
8. Deed Book No. 017377 Page No. 00645 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):
Pulte Home Company, LLC
Name
[e-mail]
E-mail Address
1225 Crescent Green Dr. Suite 250 Same
Current Mailing Address Current Street Address
Cary, NC, 27518 Same
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina - 401 Old Honeycutt Road, Fuquay-Varina, NC 27526 HE
[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
ieccive any notice, piocess, pleading in any action or prorePrfno arising out of anv matter rel?tino to the Town of
Fi-quay-Varina Land Development Ordinance and/or Land Disturbance Permit:
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:
Pulte Home Company, LLC [e-mail]
Name E-mail Address
1225 Crescent Green Dr. Suite 250 Same
Current Mailing Address Current Street Address
Cary, NC, 27518 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.
Chris Raughley
Type or print name Title or Authority
V"'
Signature
VP Land Development
13. I 'LA
Date
I, M.&V Coll !& l.lduvnot a Notary Public of the County of VV61 y'e,
State of North Carolina, hereby certify that S appeared personally
before me this day and being duly sworn acknowledged that the above f6rm was executed by him.
Witness my hand and notarial seal, this �'L day of 201,[
Seal-y=
01AR Y
PuBL'G C)
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Notary
My c m ission expires