NCC241093_FRO Submitted_20240411

C.-ARY
A
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: Life Time
PROJECT DEVELOPMENT PLAN #: 23-DP-1522
PROJECT LOCATION:
0735395493
Property Tax ID#/PIN
1120 Healthy Way
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: APRIL 2024
ACREAGE OF LAND TO BE DISTURBED: 12.22 AC (532,146 SF)
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
LTF Real Estate Company, Inc.
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.)
LTF Real Estate Company, Inc.
Name(Person or Firm)
2902 Corporate Place
Street Address(No PO Box)
Chanhassen, MN 55317
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
updated:04/2023

952-947-0000
Telephone Number
Fax Number
[e-mail] Justin Schmidt
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.)
Cogency Global, Inc.
Name
212 South Tryon Street, Suite 1000
Street Address(No PO Box)
Charlotte, NC 28281
City State Zip
866-775-0114
Telephone Number
866-775-0115
Fax Number
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.
LTF Real Estate Company, Inc. (Justin Schmidt) OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
LTF Real Estate Company, Inc.
Name(Person or Firm)
0735395493
Property Tax ID#/PIN
2902 CORPORATE PLACE
Street Address(No PO Box)
CHANHASSEN, MN 55317
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.
John D. Griffith Sr. Vice President, Real Estate &Development
Name _ Title or Authority
-�-�'� 4/1/24
Signal re '144104 Date
jgri ,[e-mail] 952-947-0000
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.)
John D. Griffith Sr. Vice President, Real Estate & Development
Type or Print Nei,- '� Title or Authority
�411 � 4/1/24
Signal tN� Date
I, rth Art cl Erickson , a Notary Public of the County of CAN(-v. '
State of Minnesota hereby certifies that III 1 n D. n l 1 h
personally appeared before me this day and under oath acknowledged that the above form was
executed by him/her.
Witness my hand and notarial seal,this IV' day of Rpri I , SO 214
V
ANDREA DAWN ERICKSON Notary Public
r�` ' Notary Public-Minnesota
My Commission Expires Jan.3l.2029 -t
,., My commission expires V anvaYsi 51,7-02,9
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