NCC230952_FRO Submitted_20230405

„ORlN CA40,'
44
Town of Cary
ri
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 NORTHWOODS JORDAN MIXED USE AND FIRST BAPTIST CHURCH PARKING LOT
PROJECT DEVELOPMENT PLAN# 22-DP-0379(NORTHWOODS JORDAN MIXED USE&21-DP-6546-A(FBC PARKING)
PORTIONS OF THE DOWNTOWN BLOCK BOUNDED BY W.CHATHAM STREET(NORTH),
PROJECT LOCATION S.HARRISON AVE(WEST),S.ACADEMY STREET(EAST)AND W.PARK STREET(SOUTH)
APPROXIMATE DATE OF PROJECT INITIATION FEBRUARY 2023
ACREAGE OF LAND TO BE DISTURBED 8.31 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 Cary,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
N/A
Fax Number
[e-mail]&[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 of Cary
316 North Academy Street,Cary,NC 27513 PO Box 8005,Cary,NC 27512-8005
Tel[phone] www.townolcarv.org
Form updated 02/17/2022

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.
OR V Mark Barker
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.)
Meridian Cary,LLC
By: NorthView Chatham,LLC,Its Manager
By:Mark R Barker.Its Manaaer
Type r Print Name
Signature
--
Signature
Manager
Title or Authority
%/a.4! ;-3
Date '
North Carolina)
LAfa 1L9 County
a Notary Public of the County of Lju�e- , North
Carolina, do hereby certify that Mar . kZtl personally appeared before me this day
and under oath acknowledgedA that the above form was executed by him/her. Witness my hand and
ssemoftnotarial seal, this oZ i V\ day of �q,VW , 02 0 ,, ���� SOW
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NOTARY . Z
Notary Public : . • •
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My commission expires �(,!2►U� t aba3 p1191.�C
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Town of Cary
316 North Academy Street,Cary,NC 27513 PO Box 8005,Cary,NC 27512-8005
Tel[phone] www.townofcarv.org,
Form updated 02/17/2022
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