NCC243273_FRO Submitted_20241024

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— 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: flrIC', s A(oliiii 69.711 e-ypc,nslun,--;
PROJECT DEVELOPMENT PLAN#: '- — D? —3 6‘-. — g
PROJECT LOCATION:
C 7-36 cc386
Property Tax ID#/PIN
) '> 'ELS Jobs PaAJ , o,leia\,-) f c7V�
Street Address J
APPROXIMATE DATE OF PROJECT INITIATION: 16 if / oz
ACREAGE OF LAND TO BE DISTURBED: ,� l'r°S
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
) ol�°74 ".,, , -
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.)
Name(Person or Firm) 1
40) Pi;,Gri;, ?Crtom\ N ' �/ N � ^'
Street Address(No PO Box) ✓
20,\p,C\\11 i,,, al66
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

C� - �� � - �� � 6
Telephone Number
Fax Number
aber . Gfle-F-� e � �iUe Aife _ cor,\
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.)
(of k4
Name
(i 61-'( I Ric pc) G rIC2 J. .
Street Address(No PO Box)
City State Zip
Telephone Number
Fax Number
1{o‘)1Zc s Co \e. e 61Aioe,
E Mail Address 1
The Town reserves the right to contact either the financially responsible person or registered agent listed
bel ase of violation. ase indicate your preference below.
,—/t4//L—e OR
Financially Responsible P on Registered Agent
Section 3
LANDOWNER OF RECORD:
Vobe A Cad�y
Name(Person or Firm)
Property Tax ID#/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.go\
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.
i obZ L,,A�
Name Title or Authority
41Z-egLe 1
gnature 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.)
Typp not N e Xezi Title or Authority
O6 _ ZaZY
na a Date
I, �(N,c,A 1Q O , a Notary Public of the County of QiValA�� ,
State of North Carolina, hereby certifies that ld3. V L
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 I� � ,
„„i111,,,
\\\\\\..s.1\1 E pF///ii
_ co OTAR y
Se _ Notary Public
P U B t-\G _, My commission expires
9d}q1
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