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HomeMy WebLinkAboutNCC231337_FRO Submitted_20230707 „Q` 4 i r 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 CHAIRMAN@SVTEMPLENC.ORG 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(919)469-4030 %%,‘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(91))469-030 w.tnwnof can.org Forst updated 0277 2022