NCC240938_FRO Submitted_20240402

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: DENC Energy Center
PROJECT DEVELOPMENT PLAN#: 20-7290
PROJECT LOCATION:
Tax ID: 56-2128483 PIN: 0774248381
Property Tax IDII/PIN
7601 Chapel Hill Road, Cary NC 27513
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: 04.01.2024
ACREAGE OF LAND TO BE DISTURBED: 1.5
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership(FR/O) Form.)
Scott Beckett
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.)
Public Service Company of North Carolina, Inc.
Name(Person or Firm)
800 Gaston Road
Street Address(No PO Box)
Gastonia, NC 28056
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

804-380-9335
Telephone Number
Fax Number
[e-mail]
E-Mail Address
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.
X OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
Public Service Company of North Carolina, Inc.
Name(Person or Firm)
Tax ID: 56-2128483 PIN: 0774248381
Property Tax IDti/PIN
800 Gaston Road
Street Address(No PO Box)
Gastonia, NC 28056
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.
Scott Beckett Director Facilities Management
Name Title or Authority
Signature Date
courtney.r.clements©dominionenergy.com 804-380-9335
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.)
Scott Beckett Director Facilities Management
Type or Print Name Title or Authority
Signature Date
fr 1'W / I (-4/l t!'`W / , a NNtary Public of the County of OtZt/dhi07(
/� t
State of Nehr�6a , hereby certifies that `.)(�o T i ��r �()Cl/�(`'�`'
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 day of ar d ,
le-00401A,
•5c€x! MONIQUE MCMICHAEL Notary Publ'
a r m Notary Public l �V �
Y ° State of Ohio My commission expires
s a o My Comm. Expires
Y° '��c ,u o` April 19, 2026
ro
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