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Home My WebLink AboutNCC242134_FRO Submitted_20240717 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: AC llotcl PROJECT DEVELOPMENT PLAN#: 23-DP-2787 PROJECT LOCATION: 0462714/0736216786 Property Tax ID#/PIN 4917 NC 55 Cary,NC 27519 _ Street Address APPROXIMATE DATE OF PROJECT INITIATION: September 2024 ACREAGE OF LAND TO BE DISTURBED: 3 11 Acres APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2 of the Financial Responsibility/Ownership(FR/O) Form.) Cary Hoicl, Inc. 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.) Cary Hotel,Inc. Name(Person or Firm) 711 Gallimore Dairy Road Street Address(No PO Box) High Point, NC 27265 City State Zip Cary 318 North Academy Street, Cary,NC 27513 PO Box 8005, Cary, NC 27512-8005 Tel: 311 or 919-469-4000 outside Cary limits www carync qov updated 04/2023 919-225-7744 Telephone Number rva Fax Number karan(a;cnhotcls.net 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.) Koran Patel Name 711 Gallimore Dairy Road Street Address(No PO Box) high Point, NC 27265 City State Zip 919-225-7744 Telephone Number n/a Fax Number karan@cnhotcls.nct 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. Nayan Patel OR Finanaally Responsible Person Registered Agent Section 3 LANDOWNER OF RECORD: Cary Hotel,Inc Name(Person or Firm) 0462714/0736216786 Property TaxIN/P!N 711 Gallimore Dairy Road Street Address(No PO Box) High Point,NC 27265 City State Zip Gary 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 ownei 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. Nayan Patel President Nemo Tale orAufhonty Sig arum Date .S�.c �Q- fro s_._y e + 336 - 5 77- MS- - Emod 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.) Nayan Patel President Type orPnnt Name TRIe or Authority' •ID---- ___6/2r/Z S/Liro Dafo 1, Tale( , a Notary Public f(�thecCounty of L,C11--\_ at ,, State of rth Carolina, hereby certifies that 1V t'Bit � personally appeared before me this day and under th acknowledged that the above form was executed by him/her. 1 1 Pen Witness my hand and notarial seal,this L- day of i Lift, , 2-t_J2-�1 NEON TUCKER Utt "'~ Sea NOTARY RAC Notary '�.lic RANDOM COUNTY NC 2 p �� I*1 My commission expires 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