NCC240946_FRO Submitted_20240402

CARY
— NORTH CAROLINA —
Stormwater Division
FINANCIAL RESPONSIBILITY - OWNERSHIP FORM
No person may initiate any land-disturbing activity covered by Cary's Sedimentation and Erosion Control
Ordinance before completing and filing this form with the Cary Stormwater Division. Indicate N/A if a
question is not applicable.
Section 1
PROJECT NAME: THE LIVANO CARY
PROJECT DEVELOPMENT PLAN #: 22-DP-5630
PROJECT LOCATION:
REAL ID:0037061/PIN:0772-49-7496
Property Tax IDA/PIN
109 PINEY PLANES ROAD,CARY,NC
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: 12/22/2021
ACREAGE OF LAND TO BE DISTURBED: 16.22 AC
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
Piney Plains Residences, LLC
Name(Person or Firm)
Section 2
PERSON(S) OR FIRM(S) FINANCIALLY RESPONSIBLE FOR THIS LAND-DISTURBING ACTIVITY:
(If out of state, a registered agent in North Carolina must be used.)
Piney Plains Residences, LLC
Name(Person or Firm)
2204 Lakeshore Drive Suite 450
Street Address(No PO Box)
Homewood, Alabama 35209
City State Zip
Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carvnc.gov
updated:04/2023

[phone]
Telephone Number
[phone]
Fax Number
[e-mail]
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE
(If out of state, a registered agent in North Carolina must be used.)
Paracorp
Name
176 Mine Lake Ct#100
Street Address(No PO Box)
Raleigh, NC 27615
City State Zip
[phone]
Telephone Number
[e-mail]
Fax Number
[phone]
E-Mail Address
The Town reserves the right to contact either the financially responsible person or registered agent listed
below in case of violation. Please indicate your preference below.
Piney Plains Residences, LLC OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
Piney Plains Residences, LLC
Name(Person or Firm)
REAL ID: 0037061 / PIN: 0772-49-7496
Property Tax/D#/PIN
2204 Lakeshore Drive Suite 450
Street Address(No PO Box)
Homewood, Alabama 35209
City State Zip
Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carync.gov
Page 2 of 3 updated:04/2023

STATEMENT OF LANDOWNER CONSENT:
In accordance with NCGS 113A-54.1(a), I hereby declare that I am the owner or legally authorized
representative of the owner of the property described above and provide my consent for the applicant
cited in Section 1 above to submit an erosion control plan to the Town of Cary Stormwater Division and to
conduct the planned land-disturbing activities on the property listed in Section 1 above.
Jason W. Bailey Authorized Signatory - Piney Plains Residences, LLC
Name Title or Authority
Signature Date
[e-mail] [phone]
Email Telephone Number
THE ABOVE INFORMATION is true and correct to the best of my knowledge and belief and as provided
by me while under oath. (This form must be signed by the financially responsible person, if an
individual or by an officer, director, partner, attorney-in-fact, or other person with authority to
execute instruments for the financially responsible person if not an individual.)
Jason W. Bailey Authorized Signatory - Piney Plains Residences, LLC
Type or Print Name Title or Authority
Signature Date
I, I 1 L"t I'vt v 1 1• SW4 flceAl , a Notary Public of the County of JeKers°
State of • , hereby certifies that J0150 In i3ci i I ey
personally app ar d before me this day and under oath acknowledged that the above form was
executed by him/her. I_ L
Witness my hand and notarial seal,this I S7— day of �q 0 f7l 2 0? '
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Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carync.gov
Page 3 of 3 updated:04/2023