NCC223307_FRO Submitted_20220921

FJOJ/Vr VAP 11 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 Atwater Station Subdivision - Phases 1. 2. 3. & 6
2. Location of land -disturbing activity: Highway/Street_South of Bass Lake Road, -East and West of James Slaughter Road
3, Approximate date land disturbing activity will commence: ,January 1. 2022
4. Type of development (residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 58.0 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jay Gillilan E-mail Address [e-mail]
Telephone [phone] Cell #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached list.
Name E-mail Address
Current Mailing Address
City State Zip
Current Street Address
City State Zip
8. Deed Book No. Page No. 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):
Jay Gillilan jgillilan@ bakerresidential.com
Name E-mail Address
One West Red Oak Lane
Current Mailing Address Current Street Address
White Plains, NY 10604
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina = 401 Old Honeycutt Road. Fuquay-Varina NC 27526
[phone] = fuquay-vanna 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 INsturbance Permit_
Name
Current Mailing Address
City State Tip
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:
Jay Gillilan [e-mail]
Name E-mail Address
2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Strut Address
Raleigh, NC 27608
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.
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a Notary Public of the County of &K
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him_
Witness my hand and notarial sea], this 21 day of tJQ , 24iL__
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. Landowner(s) of Record (attach accompanied page to list additional owners):
Lynn S. Trustee Mills
lame
E-mail Address
85 Dexterfield Dr. 3121 James Slaughter Rd.
:urrent Mailing Address
Current Street Address
-u ua -Varina NC 27526-8010 Fuquay-Varina, NC 27526
:ity State Zip
. Deed Book No. 11377
Page No. 0361
City State Zip
Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
Edith W. Flowers Holleman
lame E-mail Address
800 Base Lake Rd. 3232 James Slaughter Rd. & 1800 Bass Lake Rd_
,urrent Mailing Address
Current Street Address
Fuquay-Varina, NC 27526-9074 Fuquay-Varina, NC 27526-8297
ity State Zip City State Zip
Deed Book No. 02604 & 02294 Page No. 0082 & 0083 Provide a copy of the most current deed.