NCC241069_FRO Submitted_20240410

DocuSign Envelope ID:645EFB68-348A-459C-9BBC-D5669197ECE1
C tAt RY
-- 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: 0 Green Level Church Road - Tree Clearing Certificate
PROJECT DEVELOPMENT PLAN#: 24-TC-5857
PROJECT LOCATION:
0727909386
Property Tax ID#/PIN
0 Green Level Church Road; Cary, NC 27519
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: 04/2024
ACREAGE OF LAND TO BE DISTURBED: 4.25
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
Drew Thigpen (GGP Park Overlook East LLC)
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.)
Drew Thigpen (GGP Park Overlook East LLC)
Name(Person or Firm)
4929 Monroe Road
Street Address(No PO Box)
Charlotte, NC 28205
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.carvnc.cov
updated:0412023

DocuSign Envelope ID:645EFB68-348A-459C-9BBC-D5669197ECE1
843-469-2517
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 7/7- > _ OR
Financially Responsibl erson Registered Agent
Section 3
LANDOWNER OF RECORD:
Green, Lucille B & Kevin A
Name(Person or Firm)
0727909386
Property Tax ID#/PIN
2321 EVANGELINES WAY
Street Address(No PO Box)
VIRGINIA BEACH, VA 23451-1077
City State Zip
Cart/
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

DocuSign Envelope ID:645EFB68-348A-459C-9BBC-D5669197ECE1
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.
Mildred G. malearlie GreffairOld E. Grii8W11,n J •.. Green
Name Title or Authority
ara G � ,E. Cty, /tjv� rch 28, 2024
Signature55'' ate
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.)
Drew Thigpen (GGP Park Overlook East LLC) Vice President/Partner
Type or Print Name Title or Authority,
Si ature - Date ,
I, / &if +tom , a Notary Public of the County of (1/0 It r.. ,
State of North Carolina, hereby certifies that - uw 7 A C r ,J
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 27 day of 1(-' -)- tr , 7,_0 Z I
- Notary Public
''
• My commission expires -lea
?5J�, r eye
} 9
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