NCC242502_FRO Submitted_20240816

DocuSign Envelope ID:293199C0-CC41-41D1-90F4-CD56B1879C80
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: FENTON DEVELOPMENT—QUINARD DRIVE EXTENSION
PROJECT DEVELOPMENT PLAN #: 19-DP-5300-E
PROJECT LOCATION:
N/A
Property Tax ID#/PIN
Quinard Drive
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: JULY 1, 2024
ACREAGE OF LAND TO BE DISTURBED: 2.3 ACRES
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
USEF HCG Fenton, 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.)
USEF HCG Fenton, LLC
Name(Person or Firm)
201 Fenton Gateway Drive, Suite 010
Street Address(No PO Box)
Cary, NC 27511
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
updated:04/2023

DocuSign Envelope ID:293199C0-CC41-41D1-90F4-CD56B1879C80
770-206-5333
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.)
Chicago Title Company
Name
19 W. Hargett St., Suite 507
Street Address(No PO Box)
Raleigh, NC 27601
City State Zip
888-690-7384
Telephone Number
913-489-5231
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.
USEF HCG Fenton, LLC _ OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
Name(Person or Firm)
Property Tax IDA/PIN
Street Address(No PO Box)
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

DocuSign Envelope ID:293199C0-CC41-41D1-90F4-CD56B1879C80
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.
Name Title or Authority
Signature Date
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.)
Kurt Hartman SMD
Type or Print Name Title or Authority DS DS
�DocuSigned by: ^
tkArtouttA, 6/13/2024 ' 19'Z
Signature F3BFD5912FE1494... Date
I, 0-09tv-G(.V) C1 awi (/i , a Notary Public of the County of I/l)Gtk t� ,
State of North Carolina, hereby certifies that k-0 4- Z vi-vvi a VI.
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 1 day of d14,tne,
ef, o,;(,a/t 4-yi7 d(44J 'l -
Notary Public v
RE .AH GOODWIN
NOTARY PUBLIC My commission expires % VE 1 2-t! Zbz -1
Wake County +
North Carolina
My Commission Expires April 24,2027
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