NCC221227_FRO Submitted_20220330

10/6/21, 3:00 PM Financial Responsibility - Ownership Form I Town of Cary
FINANCIAL RESPONSIBILITY - OWNERSHIP FORM
TOWN OF CARY
FINANCIAL RESPONSIBILITY - OWNERSHIP FORM
No person may initiate any land -disturbing activity covered by the Town of Cary Sedimentation and Erosion
Control Ordinance before completing and filing this form with the Town of Cary Erosion Control Division.
Indicate N/A if a question is not applicable.
PROJECT NAME
Young Farm
PROJECT LOCATION
10209 Morrisville Parkway
APPROXIMATE DATE OF PROJECT INITIATION Oct/Nov 2021
ACREAGE OF LAND TO BE DISTURBED 68. 73-acres
PERSON(S) OR FIRMS) FINANCIALLY RESPONSIBLE FOR THIS LAND -DISTURBING ACTIVITY: (If out of
state, a registered agent in North Carolina must be used.)
�[ • r p mill � � �+�� �i
Name (Person or Firm)
/ SSo / Wes- h' t o o
StreetAddress (No PO Box)
Csv � Mc Z `fir"
City State Zip
`119— Vol- 12
Telephone Number
Fax Number
M .iJ 4. e o M
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Name
Street Address (No PO Box)
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10/6/21, 3:00 PM
Financial Responsibility - Ownership Form I Town of Cary
City State Zip
Telephone Number
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.
C11744
Financially Responsible Person ---- ------------------------------------------___-__Registered Agent
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.
Date
o- is-2
L/�" 1't Dtvt a�d,o iKc/IT
Title or Authority
Signature Signature
Aa,. �_ Air
Type or Print Name
Title -------------------------- Date
+�ti.iniwe.�r►
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UBC-
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Pa Notary Public of the County of �, �, State of
No Carolina, hereby ce ' es that 0
CLi la Z I personally appeared before me this day and under oath
acknowledged that the above form was executed by him. M� ex-f s S 1 t'1k23
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10/6121, 3:00 PM
Witness mv. hand
fVatai _t [b[i;C
My commission expires
Financial Responsibility - Ownership Form I Town of Cary
this '8'-'tL day of 0 C�NJQex UZ
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