NCC223603_FRO Submitted_20221020

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
N Harrison Hotels
PROJECT LOCATION
1623 N Harrison Avenue
DATE OF PROJECT INITIATION -May 1st, 2020
ACREAGE OF LAND TO BE DISTURBED
APPROXIMATE
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.)
CS Cary Hotel, Inc.
Name (Person or Firm)
3810 N. Elm Street Suite # 202
Street Address (No PO Box)
Greensboro, North Carolina 27455
City State Zip
[phone]
Telephone Number
NIA
Fax Number
jon.daly@dalyseven. com
E MaiI Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
.�To
Name
3810 N. Elm Street Suite #202
Street Address (No PO Box)
Greensboro, North Carolina 2Z455
City State Zip
Telephone Number

A
Fax Number
jon.daly@dalywiv .con
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.
on M.
OR
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
white 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.
Z/-ZO
Date
President
Title orAut 'ty
Sig re
Ton M. Daly
Type or Print Name
Title -------------------------- Date
1 c r e :S Q H CLA k , a Notary Public of the Gaa of --D a -v , i l e State of
Virginia, hereby certifies that
,yr. r� . ` D c- 4!N -personally appeared before me this day and under oath
acknowledged that the above form was executed byhim.
Witness my hand and notarial seal, this-L�jday off{
-Votary Public _ <, ._ : sr�a, . • . _ �;
Twn�_sA';. dALt-
My commission expires Jdfx. _3 11, Z C);2 13 , W.ma ry P' A
Comr""'P?'Jij, of'a'r•'nia
Regtst�atian *o. 35 {q )6
i1,y Commiss�nn r".;(ptre5 Jan "s ; 7q