NCC231342_FRO Submitted_20230508

10/6/24,3:00 PM Financial Responsibility-Ownership Form I Town of Cary
FINANCIAL RESPONSIBILITY - OWNERSHIP FORM
TOWN OF CARY
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 Erosion Control Division.
Indicate N/A if a question is not applicable.
PROJECT NAME
Twyla Road South - Phase 1 & 2
PROJECT LOCATION
7216 Green Hope School Road
APPROXIMATE DATE OF PROJECT INITIATION Summer 2022
ACREAGE OF LAND TO BE DISTURBED 18 .10-acres
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.)
Name(Person or Firm)
Street Address(No PO Box)
City State Zip
Telephone Number
Fax Number
c',1-6( )' • COW
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Name
Street Address(No PO Box)
https://www.townofcary.org/business-development/field-services/financial-responsibility-ownership-form 1/3

10/6/21,3:00 PM Financial Responsibility-Ownership Form I Town of Cary
N L-2 -1-*p
City State Zip
Telephone Number
Fax Number1r�I
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 Aged
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.
572Y/ats-
Date
Dl✓lgtr oc L ug phi Ur 6o1)04.e.4-)
Title or thorny
4
Signature Signature
lig ivtJ K rct fig
Type or Print Name
Title Date
_ J C4 6-1 vl 4 _, a Notary Public of the County of V V k , State of
North Carolina,hereby certifies that
( V\ -t.4C1-N.2 in/1 personally appeared before me this day and under oath
acknowledged that the above form was executed by him.
https://www.townofcary.org/business-development/field-services/financial-responsibility-ownership-form 2/3

10/6/21,3:00 PM Financial Responsibility-Ownership Form I Town of Cary
Witness my hand and notarial seal,this day of 4 , 7i67_2.
(-.>19104414 qijft--
Nota y Public \\\\�a►►iuinio,,���
My commission expires I `1_� .-3 . . ..04 ALE K �''�.,Z`
'T „NA ,e
�o� �a �ti� +c. Q
Co Ott`•13 Z
https://www.townofcary.org/business-development/field-services/financial-responsibility-ownership-form 3/3