NCC230805_FRO Submitted_20230327

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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 Dam Breach, -FsI,&„ZWst E!Ql]d,s,
2. Location of land -disturbing activity: Highway/Street 1816 & 3101 James Slau ht r Rd.
3. Approximate date land -disturbing activity will commence: F@_�rugry 2Q23
4. Type of development (residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas): 7.70 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Gray Metbven E-mail Address_ gmefhyan(cbhgkerreSidgi3im il.GQM
Telephone [phone] Cell # 919-398-3371 _
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Baker Residential of the Carolinas, LLC jgillilan() askerresidential.com
Name E-mail Address
7001 Weston Parkway. Suite 150 7001 Weston Parkway, Suite 150
Current Mailing Address Current Street Address
Cary, INC 27513 Cary, NC 27513
City State Zip City State Zip
8. Deed Book No. 18727 Page No. 441 Provide a copy of the most current deed.
Part B. 18727 432
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):
maker Residential of the Carolinas. LLC _jgillilan gr7baskerresidential.com
Name E-mail Address
7S2Q1Weston _Parkway- _ Suite 150 7 P r
Current Mailing Address Current Street Address
Cary. NC 27513 Cary, NC 27513 _
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina HE 134 N Main Street, Fuquay-Varina, NC 27526
[phone] HE 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:
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:
Jav Gillilan ioillilan _baskerresodential.com
Name E-mail Address
7001 Weston Parkway, Suite 150 7001 Weston Parkway, Suite 150
Current Mailing Address Current Street Address
Cary, NC 27513
City State Zip
Carv. NC 27513
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.
_,la�Gillilaa. Div. Pres.. Baker Residential of the Carolinas. LLC
Type or print name itle or Authority
7' 1 7-5
Signat ED) I e
1, aka n a Notary Public of the County of
State f North Carolina, hereby certify that Jay Gillilan 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 day of 20 7-3
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My &mmi6sion expires
20221201