NCC223699_FRO Submitted_20221102

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FUQ J/-\\(-\l/- R IN A
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 Meadow Bluffs - Phases 4 & 5 Lots 101-142, 163-172, 201-204
2. Location of land -disturbing activity: Highway/Street High Plains Drive, Violet Way & Moonraker Drive
3. Approximate date land -disturbing activity will commence: Summer 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): 10.54 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Blake Massengill E-mail Address blake.massengill(a gmail.com
Telephone [phone] Cell # 919.614.2911
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Massengill Design Build, LLC blake.massengill(d_)gmail.com
Name E-mail Address
8109 Woodcrest Court 8109 Woodcrest Court
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip 017251 698 City State Zip
8. Deed Book No. 18196 Page No. 2057 Provide a copy of the most current deed.
18183 2060
Part B. 18713 1059
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):
Massengill Design Build, LLC [e-mail]
Name E-mail Address
8109 Woodcrest Court 8109 Woodcrest Court
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Telephone [phone]
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:
Jonathan Blake Massengill [e-mail]
Name E-mail Address
8109 Woodcrest Court 8109 Woodcrest Court
Current Mailing Address Current Street Address
Fuquay-Varina NC 27526 Fuquay-Varina NC 27526
City State Zip City State Zip
Telephone [phone]
(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 Fin anci Ily Responsible Party is a Corporation, give name
and street address of the Re istered Agent:
N I0Gi E-mail Address
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C Frrent Mailing Address Current Street Address
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City State tp ! � / 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.
Jonathan Blake Massengill Managing Member
Typ p i t came Title or Authority
ignature Date
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I, )Ann(% `� } �. 1 w , a Notary Public of the County of WCiA_'11e_
State of North Carolina, hereby certify thatappeared personally
before me this day and being duly sworn acknowledged that the above rm was executed by him.
Witness my hand and notarial seal, this _day of mQ`iCC \ 20 a o
Hannah Shaw
Seal NOTARY PUBLIC
Wake County, NC
My Commission Expires December 07, 2026
Notary
Z�et._�,aoa(a
My commission expires