NCC230731_FRO Submitted_20230320

I- -- � - Town of Cary
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 Alta IvF.K.A. " a enter Fir- tati n A partments")
PROJECT DEVELOPMENT PLAN # 22-DP-3723
PROJECT LOCATION 4011 NC 55 HWY: Cary. NC 27612
APPROXIMATE DATE OF PROJECT INITIATION 12/1/2022
ACREAGE OF LAND TO BE DISTURBED 17.0
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.)
Carpenter Fire Station Apartments Owner, LP
Name (Person or Firm)
1414 Raleigh Road, Suite 429
Street Address (No PO Box)
Chapel Hill, NC 27517
City State Zip
919-355-0110
Telephone Number
Fax Number
[e-mail]
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Jon Callahan
Name
333 Wade Avenue
Street Address (Np PO Box)
Raleigh, NC 27605
City State Zip
Town o
316 North Academy Street, Cary, NC 27513
Tel [phone]
PO Box 8005, Cary, NC 27512-8005
WWw.tnwnnfearv.drg
Form updated 0211712022

919-828-4428
Telephone Number
rax rvumoer
[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.
El
Financially Responsible Person
OR
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.)
Caitlin Shelby
Type or Print Name
Sibrgfure
Authorized Representative
Title or Authority
1� / LY/ZvZZ
Date
North Carolina
\lgt _�_, County
1, &L CA,otc.-5 F Vqt s , a Notary Public of the County of `Al c_�-e . North
Carolina, do hereby certify that C_0,i + 1iw L. 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 1/ day of Ai oyer toe!" I 2a 2Z .
Notary Public
My commission expires 3/30 (ZaZ7.
Nicholas B. West
NOTAfiy PUBLIC
Wake County, NC
My Commission Expires March 30, 2027
Town of Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel [phone] www.towl "Of .ora
Form updated 0211712022
page 2