NCC220756_FRO Submitted_20220216

Submit to the Water Resources Department, 316 N. Academy St., Cary, NC 27513
Town of Cary
Water Resources Department
Financial Responsibility - Ownership Form
No person may initiate any land -disturbing activity covered by the Town of Cary Sedimentation and
Erosian Control Ordinance before completing and tiling this form with the Town of Cary Stormwater
Division. Indicate NIA if a question is not applicable.
PROJECT NAME Weatherstone Creek Condominiums
PROJECT LOCATION
APPROXIMATE DATE OF PROJECT INITIATION
ACREAGE OF LAND TO BE DISTURBED
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,)
ExperienceOne Homes, LLC
Name (Person or Firm)
116 Turquoise Creek Dr.
Street Address (No PO Box)
Cary, NC 27513
City Stare zip
919 991 -1428
Telephone Number
[phone]
Fax Number
CSchmidt@E1 homes.com
E-Mai! Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
ExperienceOne Homes, LLC
Name
116 Turquoise Creek Dr.
Street Address (No PO Box)
Cary, NC 27513
City State Zip
[phone]
Telephone Number
[phone]
Fax Number
CSchmidt(d)E1 homes.com
E-Mafl Address
TOWN of CA.RY
316 North Academy Street • Cary, NC 27513 • PO Box 8005 • Cary, NC 27512-8005
te1919-469-4030 • fax [phone] • www.townofcary.org

The Town reserves the right to contact either the financially responsible person or registered agent listed
below in case of violation, Please indicate your prefer e below.
OR
Financially Responsible Person Registered Agerh
THB 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.
Corey Sc i t
Ty or rint
Sigrtat re
Manacler/Owner
Title orAut rity
Date
North Carolina
County
,tea Notary Public for County, North Carolina, do
hereby certify that-�y���C�[y.;,�eonall came before me this day and acknowledged
that he is and �l\���
acknowedged, on behalf of
N-11Kti1-14e due execution of the foregoing instrument.
Witness my hand and official seal, this the ` � day of-: 20 -7�-.
=JACQUELINEL.SNotary Public �
My commission expires 20Z�
TOWN Of CARY
316 North Academy Street • Cary, NC 27513 • PO Box 8005 a Cary, NC 27512-8005
tel [phone] • fax [phone] • ,vww.to%timofcary.org
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