NCC233194_FRO Submitted_20231025

FUQU4`(-\/4R ! Ian
north carolina
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 Bentwinds Bluffs Phases 4 & 5
2. Location of land-disturbing activity: Highway/Street 6717 Old Mills Road, Fuquay-Varina,NC 27526
3. Approximate date land-disturbing activity will commence: Spring 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): 5.78
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Andy Petty, PE E-mail Address [e-mail]
Telephone [phone] Cell # 910.624.5215
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Bentwinds Massengill, LLC
Name E-mail Address
8109 Woodcrest Court same
Current Mailing Address Current Street Address
Fuquay-Varina, NC 27526-9404 same
City State Zip City State Zip
8. Deed Book No. 018577 Page No. 01221 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):
J. Wayne Massengill [e-mail]
Name E-mail Address
6600 Brookshire Drive same
Current Mailing Address Current Street Address
Fuquay-Varina, NC 27526 same
City State Zip City State Zip
Telephone [phone]
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:
Thurston Debnam
Name E-mail Address
4601 Six Forks Road Suite 400 Same as mailing
Current Mailing Address Current Street Address
Raleigh, NC 27609 Same as mailing
City State Zip 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:
Name E-mail Address
Current Mailing Address Current Street Address
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.
J. Wayne Massengill -Owner
Type or print name Title or Authority
,4Y 1/
Si ture Date
I, 01.1N4319p1Pert3. �.`"t'` , a Notary Public of the County of OcaL L
State of North Carolina, hereby certify that --D—• Wes- %( Mcisse- C I. 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 tC_ . 20 Z
CHRISTOPHER W. SMITH Notary
Seal Notary Public r Zj Z�—/
Harnett Co., North Carolina My co ission expires
My Commission Expires Aug.25,2024