NCC240844_FRO Submitted_20240325

CARY
— NORTH CAROLINA —
Stormwater Division
FINANCIAL RESPONSIBILITY -OWNERSHIP FORM
No person may initiate any land-disturbing activity covered by Cary's Sedimentation and Erosion Control
Ordinance before completing and filing this form with the Cary Stormwater Division. Indicate N/A if a
question is not applicable.
Section 1
PROJECT NAME: Park Overlook
PROJECT DEVELOPMENT PLAN #: 21-DP-10017
PROJECT LOCATION:
0737103369
Property Tax ID#/PIN
4000 & 4010 Park Overlook Way - Cary, NC 27519
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: ASAP
ACREAGE OF LAND TO BE DISTURBED: 23.29 AC
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership(FR/O) Form.)
V re kJ 71 1)ee.
Name(Person or Firm)
Section 2
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.)
/U/Li_e—/ / /��j/*,"
Name(Person or Firm)
Street Address(No PO Box)
",260 / /vC 2eY2o
City State Zip
Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel:311 or 919-469-4000 outside Cary limits www.carync.gov
updated:04/2023

,s43 - 4199 - z5►7
Telephone Number
Fax Number
d+11. 40e Cd cle\Corhinierb0.J , corms
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE.
(If out of state, a registered agent in North Carolina must be used.)
Name
Street Address(No PO Box)
City State Zip
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
Section 3
LANDOWNER OF RECORD:
GGP Park Overlook East LLC
Name(Person or Firm)
0737103369
Property Tax'Ott/PIN
2077 Somerville Road; Suite 310
Street Address(No PO Box)
Annapolis, MD 21401
City State Zip
Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carync.gov
Page 2 of 3 updated:04/2023

STATEMENT OF LANDOWNER CONSENT:
In accordance with NCGS 113A-54.1(a), I hereby declare that I am the owner or legally authorized
representative of the owner of the property described above and provide my consent for the applicant
cited in Section 1 above to submit an erosion control plan to the Town of Cary Stormwater Division and to
conduct the planned land-disturbing activities on the property listed in Section 1 above.
Name Title or Authority
6,/-5/Z3
Si ature Date
Email Telephone Number
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.)
/2i°Srdr=
Type or Print Name Title or Authority
Si ure Date
I, KJ€A , \QOS , a Notary^ Public-ofof the County of V�10. ,
State of North Carolina, hereby certifies that T )f P tA.) 1 i/11 Q per)
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 ,5 day of —U t,1.J\Q , aoa�
Karen L. Haas 0' 761Z
NOTARY PUBLICWake County No �'���
ary Public
Sea/North Carolina
My Commission Expires August 8,2026
oa�2,a5oo1$°� My commission expires W jg a0
a
Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carync.gov
Page 3 of 3 updated:04/2023