NCC216971_FRO Submitted_20211216

Submit to the Water Resources Department, 316 N. Academy St., Cary, NC 27513
Town of Cary
Water Resources Department
Financial Responsibility - Ownership Farm
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 Searstone Retirement Community Phase 2
PROJECT LOCATION East Side of Davis Drive, just South of High House Road
APPROXIMATE DATE OF PROJECT INITIATION December 2021
ACREAGE OF LAND TO BE DISTURBED +/- 10.8
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.)
Clancy & Theys Construction Company Attn.: John Andras, Vice President of Preconstruction
Name (Person or Firm)
421 N. Harrington Street, Suite 200
Address (No PO Sox)
Raleigh, NC 27603
City State Zip
919-834-3601
Telephone Number
N/A
Fax Number
[e-mail]
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Name
Street Address (No PO Box)
State Zip
Telephone Number
Fax Number
E-Mail Address
TOWN OfCARY
316 North Academy Street • Cary, NC 27513 • PO Box 8005 • Cary, NC 27512-8005
tel [phone] • fax [phone] • wkvw.town ofcary.org

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.
Clancy & Theys Construction Company 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 while under oath. (This form must be signed by the financially responsible person if an individual or
by an officer, director, paorney-in-fact, or other person with authority to execute instruments for
the financially responsib p son if not an individual.
John r
Type , rint ame
Vice President of Preconstruction
Title or/Authority
/ -! 41-
—Z/
Date
North Carolina
r
�f County
a Notary Public for County, North Carolina, do
hereby certify that ltW 5 personally came before me this day and acknowledged '
that he is of c- >c and acknowledged, on behalf of 1' " 5J
r, STrdl ®c the due execution of the foregoing instrument.
h
Witness my hand and of�Wl?l seal, this the day of ♦ / , 20 .
\Y O/ R
�Qr tVeJ2
Notary Public
O'RT`N �'���`�
My commission expireg �iLr. o� 20
TOWN Of CARY
316 North Academy Street • Cary, NC 27513 • PO Box 8005 • Cary, NC 27512-8005
tel [phone] • fax [phone] • "-w.townofeary.org
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