NCC241409_FRO Submitted_20240509

CARY
NO*TH 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: Lightbridge Academy-Cary
PROJECT DEVELOPMENT PLAN#: 23-DP-5758
PROJECT LOCATION:
0174054
Property Tax lDlt/PIN
655 Reedy Creek Rd
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: 5-6-2024
1.7 AC
ACREAGE OF LAND TO BE DISTURBED:
APPLICANT SUBMITTING PLAN:(must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership(FR/O)Form.)
LB Cary NC Owner 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.)
LB Cary NC Owner LLC
Name(Person or Firm)
450 Lexington Ave #4539
Street Address(No PO Box)
New York, NY 10163
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.00v
updated:04/2023

857-200-0472
Telephone Number
Fa Number
[e-mail]
E-Mall 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.)
Corporation Service Company
Name
2626 Glenwood Avenue, Ste 550
Street Address(No PO Sox)
Raleigh, NC 27608
City State Zip
800-927-9800
Telephone Number
Fax Number
[e-mail]
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.
LB Cary NC Owner LLC
OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
The Barnhill Company
Name(Person or Firm)
0174054
Property Tax IDWPIN
800 Tiffany Blvd, Ste 200
Street Address(No PO Box)
Rocky Mount, NC 27804-1807
City State Zip
Caly
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 blvision and to
conduct the planned land-disturbing activities on the property listed in Section 1 above,
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Name 4,4#.14
Title nr Authority
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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.)
LB Cary NC Owner LLC Stephen Andrews, Director
Type or Print Name Title or Authority
a A-41.---- ' 4/- tq' Z I 9 Z''t
Signal Date
I, / "ci,c`C i C labres(Z. ,allotaryPublicoftheCountyof Be.jC71 ,
(\l C_. State of Ner h-Caielfna,hereby certifies that -Si e-Aen Andre 5
7ser 47-y
persona ly appeared before me this day and under oath acknowledged that the above form was
executed by him/her.
Q +h 9
Witness my hand and notarial seal,this c I day of A P r ; U
MICHAEL CALABRESE �
Commission#50190223
Notary.Pu0lic,State of New Jersey Notary Public
Wdommissk n Expires
Mardi 31.2027 774:44,e_ __
My commission expires S / 3 l /3-7
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