NCC242422_FRO Submitted_20240808

CAPY
- 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 Residence Inn
PROJECT DEVELOPMENT PLAN #: 23-I)P-9127
PROJECT LOCATION:
0133688/0773428217
Property Tax IDN/PIN
III 9 1 edsomc Lane Cary,NC 27511
Street Address
APPROXIMATE DATE OF PROJECT INITIATION_ September 2024
ACREAGE OF LAND TO BE DISTURBED: 1.42 Acres
APPLICANT SUBMITTING PLAN (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
(iSS Raleigh,LLC
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.)
GSS Raleigh,IAA'
Name(Person or Firm)
5640 Dillard Drive St.300
Street Address(No PO Box)
Cary,NC 27518
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.carvnc.gov
updated:04/2023

919--I62-34(0
Telephone Number
n/a
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.)
Shahn Chhabra
Name
5640 Dillard Drive.
Street Address(No PO Box)
Can ,NC 27518
City State Zip
919-462-3-300
Telephone Number
n/a
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.
Shahn Chhahra OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
(iSS Raleigh.LLC
Name(Person or Firm)
0133688/0773428217
Property Tax IDA/PIN
56-10 Dillard Drive
Street Address(No PO Box)
Can,NC 27518
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.
Shahn ('hhahra Member
Name Title or Authonty
ignature Date
)4Q
[e-mail] 9 1 9-462-34.00
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.)
Shahn('hhahra Member
Type or Pnnt Name Title or Authonty
7/ad/a/
ignature Date
I, ICC\\P l‘P L. VcGICE Oy , a Notary Public of the County of ('A_Lrn'oe•
State of North Carolina, hereby certifies that YPer � hdbro
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 axis day of \.U.Adk.N , orati-
re,• •• ��
Z.0 NOTARY, * \ AD
Sj • • _` N• Public gli
cG. ►'UBOG My commission expires Cxl��o,^oa9
''.�Ft'(ANO CO �‘•
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 3 of 3 updated: 04/2023