NCC222278_FRO Submitted_20220622

7/17/2020 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
PRESTON RIDGE
PROJECT LOCATION
560 & 720 JAMES JACKSON AVENUE, CARY, NC
APPROXIMATE DATE OF PROJECT INITIATION MAY 2022
ACREAGE OF LAND TO BE DISTURBED 24.5 ACRES
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.)
zEsT�� 1 o �.� ►ems Jy
Name (Person or Firm)
so «;_= 200
Street Address (No PO Box)
-M G L E A%tj , \/ l R.. C-;' ! O 2—
City State Zip
7703. (Q� ( . '=1 Oo0
Telephone Number
Fax Number
F_P,Ith1 !._!
E-Mail Address
r.
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Clancy & Theys Construction Company
Name
2250 Shipyard Boulevard, Suite One
Street Address (No PO Box)
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7/17/2020
Wilmington, North Carolina, 28403
City State Zip
910-523-7265
Telephone Number
Fax Number
[e-mail]
E-Mail Address
Financial Responsibility - Ownership Form I Town of Cary
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.
W
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
N &T-CO 21
Signature Signature
Type or Print Name
Title --------------------------Date
a Notary Public of the County of , State-4
*0� hereby certifies that �l UM1)k:kj
personally appeared before me this day and under oath
acknowledged that the above form was executed by him.
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7/17/2020
Financial Responsibility - Ownership Form I Town of Cary
Witness my hand and notarial seal, this _ �� day of
Notary Public �1
My commission expires Un f
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