NCC241820_FRO Submitted_20240614

C RY
A
— 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: Walker Row
PROJECT DEVELOPMENT PLAN#: 22-DP-771 6
PROJECT LOCATION:
0763597484 0763599415 0763691405
Property Tax ID#/PIN
413 S Walker Street
Street Address -
APPROXIMATE DATE OF PROJECT INITIATION: 10/1/2023
ACREAGE OF LAND TO BE DISTURBED: 2.15ac
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership(FR/O) Form.)
PARK TOWNS 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.)
PARK TOWNS LLC
Name(Person or Firm)
100 E. Six Forks Rd. ste. 300
Street Address(No PO Box)
Raleigh, NC 27609
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.gov
updated:04/2023

919-389-7595
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.)
JEREMY SPIVEY
Name
100 E. Six Forks Rd. Ste. 300
Street Address(No PO Box)
Raleigh, NC 27609
City State Zip
919-2912179
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.
Josh Swindell OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
PARK TOWNS LLC
Name(Person or Firm)
822861167
Property Tax ID#/PIN
100 E. Six Forks Rd. Ste. 300
Street Address(No PO Box)
Raleigh, NC 27609
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.
Josh Swindell member
Name Title or Authority
Signa re Date
[e-mail] 919-389-7595
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.)
Josh Swindell member
Type or Print Name Title or Authority
Sign Lure Date
C.
t
I, IA ale( e\cA a Yi5i'I (
tary Public of the County of VV edL_-'�--- ,
4/State of North Carolina, hereby certifies that i DCIA SLAJ f Kit I t
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 � f--- , cz)z�3
ANNALEE RICHARDSON
Notary Public
North Carolina
Wake County Notary Public /
My commission expires / 7 I
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