NCC242759_FRO Submitted_20240909

C/ tRY
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
Twyla Road South- Commercial Outparcel
PROJECT NAME:
PROJECT DEVELOPMENT PLAN#: 23-DP-8348
PROJECT LOCATION:
0734390352
Property Tax ID#/PIN
2301 Corley Road
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: 9.3.2024
ACREAGE OF LAND TO BE DISTURBED: 1.36
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership(FR/O)Form.)
Stanley Martin Homes,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.)
Stanley Martin Homes, LLC
Name(Person or Firm)
4020 Westchase BLVD Suite 470
Street Address(No PO Box)
Raleigh NC 27607
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

919.724.0624
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.)
Brian Ketchem
Name
4020 Westchase BLVD Suite 470
Street Address(No PO Box)
Raleigh NC 27607
City State Zip
919.724.0624
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.
OR Brian Ketchem
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
Stanley Martin Homes, LLC
Name(Person or Firm)
20-8046523
Property Tax lD#/P!N
11710 Plaza America Drive,Suite 1100
Street Address(No PO Box)
Reston VA 20190
City State Zrp
Cart/
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
a

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.
Brian Ketchem Director of Land Development
e Title Authority
/. d-f 7/0 Cli
Si ure Date
[e-mail] 919.724.0624
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.)
Brian Ketchem Director of Land Development
Type t Name Title or Authority
Signaler" Date
I, . )r c\ ,n `( A ,a Notary Public of the Coup nnty�of ('� f� ,
State of North Carolina, hereby certifies that �)(`,Ql,V1, -e*(jAs_YV\
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 C_ . day of (:)\/.9 , i2- 1
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'•t,..,. ,,,,, o- 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