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HomeMy WebLinkAboutNCC216971_FRO Submitted_20211216Submit 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 johnandras@clancytheys.com 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 919-469-4030 • fax 919-460-4935 • 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 919-469-4030 • fax 919-460-4935 • "-w.townofeary.org page 2