NCC241565_FRO Submitted_20240522

AM
Town of Cary
\ ram, , Stormwater Division
316 N.Academy St.
Cary,NC 27513
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 Cloudberry Commons Townhomes
PROJECT DEVELOPMENT PLAN # 22-DP-7742
PROJECT LOCATION 7436 Roberts Road
APPROXIMATE DATE OF PROJECT INITIATION April 29, 2024
ACREAGE OF LAND TO BE DISTURBED 5.2
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.)
121 Lenox LLC/Smultron LP
Name(Person or Firm)
188 Mels Meadows Drive
Street Address(No PO Box)
—City
Varina, NC 27526
City State Zip
201-317-3793;201-306-2389
Telephone Number
Fax Number
propertyavatars(cagmaii.com
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Britt Nylund
Name
188 Mels Meadows Drive
Street Address(No PO Box)
_Fupuay Varina, NC 27526
City State Zip
Town of Cary
316 North Academy Street,Cary,NC 27513 PO Box 8005,Cary,NC 27512-8005
Tel[phone]
Form updated 02,17/2022

201-317-3793
Telephone Number
Fax Number
pro pertyevatars( (mail.corn
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.
IvnC
Financially Rcaponaible Pcr on OR Rcgiatcrcd Agcnt
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.)
cype
Britt nd
or riot N -
Sign u
Managing Member 121 Lenox LLC
General Partner of Smultron LP
Title orA' rity 6./
Date
North Carolina
Vv County
177.
, ` , a Notary Public of the County of WP.9-4siZZV-T--
, North
Carolina, do hereby certify that7-.``C1"TO personally appeared before me this day
and under oath acknowledged that the above form was executed by him/her.Witness my hand and
notari-I seal, this ' day of A L- , ,,, s MORi,41,,
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Q`- ''••s
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Notary ubl ; ' O
My commissio -xpi -s y• �•, pUB�\G ,'2
% FTT CO,,,�`'.
Town o_f Cary
316 North Academy Street,Cary,NC 27513 PO Box 8005,Cary,NC 27512-8005
Tel[phone]
Farm updated 02/17/2022
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