NCC233591_FRO Submitted_20231207

CARY
__ NORTH CAROLINA ----
Stormwater Division
FINANCIAL RESPONSIBILITY-OWNERSHIP FORM
No person may initiate any land-disturbing activity covered by Cary's Sedimentation and Erosion Control
Ordinance before completing and filing this form with the Cary Stormwater Division. Indicate N/A if a
question is not applicable.
Section 1
PROJECT NAME: The Massey Condominiums
PROJECT DEVELOPMENT PLAN #: 22-DP-9165
PROJECT LOCATION:
0763598137
Property Tax ID#/PIN
202 Byrum Street
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: 8/14/2023
ACREAGE OF LAND TO BE DISTURBED: 1.47 -
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership(FR/O) Form.)
David Gorman
Name(Person or Firm)
Section 2
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.)
202 Byrum, LLC
Name(Person or Firm)
2201 Wisconsin Ave NW STE 200
Street Address(No PO Box)
Washington DC 20007
City State Zip
Cary
316 North Academy Street, Cary,NC 27513 PO Box 8005,Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits Www.car\ncgcv
updated:04/2023

202-922-6540
Telephone Number
Fax Number
[e-mail]
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
(If out of state, a registered agent in North Carolina must be used.)
David Gorman
Name
1030 N Rogers Ln - Ste 121 #5096
Street Address(No PO Box)
Raleigh, NC 27610
City State Zip
202-670-1360
Telephone Number
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
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
202 Byrum, LLC
Name(Person or Firm)
92-2762734
Property Tax 11214/PIN
2201 Wisconsin Ave NW STE 200
Street Address(No PO Box)
Washington DC 20007
City State Zip
Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005,Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carync.gov
Page 2 of 3 updated:04/2023

STATEMENT OF LANDOWNER CONSENT:
In accordance with NCGS 113A-54.1(a), I hereby declare that I am the owner or legally authorized
representative of the owner of the property described above and provide my consent for the applicant
cited in Section 1 above to submit an erosion control plan to the Town of Cary Stormwater Division and to
conduct the planned land-disturbing activities on the property listed in Section 1 above.
David Gorman Managing Member
Name Tale orAuthonly
�It.of23
Signature Date
[e-mail] 202-922-6540
Email Telephone Number
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.)
G I a c-e C ��eS v,,re. N er -ar 'P. l 0
Type or Print Name Title orAutho y
GAL IILL SIo/13
Signature Da e
I, G iG(Cr 1`A€-eS'u , a Notary Public of the.Get -ef•D\S�t 1'\( Co` v (01 of
hereby certifies that Ddlvl Ck G D vvv ✓ ,
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 t o day of *'-' J ( , /),13Z3
l \a
!2
. CAL
O > NotaryPublic
p ; co ; DSibci
= O`, 1, & 1 My commission expires C/'7 00,
4, B A
Cary
316 Nor cademy Street, Cary, NC 27513 PO Box 8005,Cary,NC 27512-8005
Tel:311 or 919-469-4000 outside Cary limits www.carync.gov
Page 3 of 3 updated:04/2023