NCC231337_FRO Submitted_20230707

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Town of Cary
•;., Stormwater Division
- 316 N.Academ) St.
Car , NC27513
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 SRI Venkateswara Religious Hall
PROJECT DEVELOPMENT PLAN # 22-DP-6356
PROJECT LOCATION 109 Balaji Place
APPROXIMATE DATE OF PROJECT INITIATION April 1 , 2023
ACREAGE OF LAND TO BE DISTURBED 6.93 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.)
SRI VENKATESWARA TEMPLE OF NC INC
Name(Person or Firm)
121 BALAJI PLACE
Street Address(No PO Box)
CARY, NC 27513
Srate Zto
919-468-0040
Telephone Number
Fax Number
[e-mail]
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Name
Street Address(No PO Box)
City State Zip
Town of Cary
316 North Academy Street.Cary,NC 27513 PO 13ox 8005,Cary.NC 27512-11005
Tel[phone] %%,‘u.t r\kn te:n..un
Form updated Q 2:'/7 022

Telephone Number
Fax Number
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 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.)
ouwav, (-1 C-0576 ---/MI)
Type or Print N l le
(S.ig_nature /
i2
Title o Authority
Date
North Carolina
County
(AV e_ M. c-)- , a Notary Public of the County of North
Carolina, do hereby certify that P14-v6-(v t—• qLY►', 31- (1(ppersonally 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 11 elf' day of /' u��C(1 ����
` u�!��f ti �
Notary Public , I --1 C
My commission expires /V - 1,� �t�t.'-`1 f ; A 3
yes V \G
�C/OrUi
Town of Can,'
316 North Academy Street.Cary.NC 27513 PO Box 8005.Cary.NC 275 t 2-5005
Tel[phone] w.tnwnof can.org
Forst updated 0277 2022