NCC230292_FRO Submitted_20230207

~~~ Town of Cary
�fk, ,e„ Stormwater Division
316 N. Academy St.
Cary, NC 27513
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 Stormwater
Division. Indicate N/A if a question is not applicable.
PROJECT NAME Meridian East Chatham
PROJECT DEVELOPMENT PLAN # 21-DP-1741
PROJECT LOCATION 50 Hunter Street (existing address 229 E Chatham St)
APPROXIMATE DATE OF PROJECT INITIATION Between November and December of 2022
ACREAGE OF LAND TO BE DISTURBED 3.70 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.)
Meridian East Chatham, LLC
Name (Person or Firm)
6131 Falls of Neuse Road, Suite 202,
Street Address (No PO Box)
Raleigh, NC 27609
City State Zip
919-926-4760 and 919-277-1132
Telephone Number
919-878-0975
Fax Number
[e-mail] and [e-mail]
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Mark Barker
Name
6131 Falls of Neuse Road, Suite 202,
Street Address (No PO Box)
Raleigh, NC 27609
City State Zip
Town o Ca
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel [phone] w1"'v.1o'w11o,f'carV.ore
Form updated 0211712022

919-277-1132
Telephone Number
919-878-0975
Fax Number
[e-mail]
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.
Financially Responsible Person
OR V Mark Barker
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.)
Meridian East Chatham, LL
By: NorthAew East Chatham, LLC, Its Manager
By: Mark R Barker, Its Manager
Type or Print Name
Kai K. 6�—
Signature
Manager
Title or Authority
9/09/22
Date
North Carolina
kA}A e— County
!, (- 4m t SCU-3e r.S , a Notary Public of the County of WAIIL , North
Carolina, do hereby certify that M0.K, R_ &2 r 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 day of $paycr
"■.
i %0YARY r:
Notary Public
My commission expires PUBLIC
r
y"Zo"Cou y�',�s�.
Town of Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel [phone] �� w w,towlto l cari '01
Form updated 0211712022
page 2