NCC233430_FRO Submitted_20231120

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: Carpenters Point Phase 3
PROJECT DEVELOPMENT PLAN #: 21-DP-3285-C
PROJECT LOCATION:
0735-63-0418
Property Tax ID#/PIN
6920 Indian Wells Road
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: July, 2023
ACREAGE OF LAND TO BE DISTURBED: 6.82 Acres
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
Beazer Homes - Raleigh Division
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.)
Beazer Homes - Raleigh Division (Matt Christensen)
Name(Person or Firm)
801 Corporate Center Drive, Suite 300
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.carync.gov
updated:04/2023

828-371-1907
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.)
Matt Christensen
Name
801 Corporate Center Drive, Suite 300
Street Address(No PO Box)
Raleigh, NC 27607
City State Zip
828-371-1907
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.
Matt Christensen OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
Beazer Homes, LLC
Name(Person or Firm)
0735-53-5359, 0735-53-7432, 0735-63-0418
Property Tax ID#/PIN
801 Corporate Center Drive, Suite 300
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.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 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 plannede/mo land-disturbing activities on the property listed in ,Se�ctioonn 1/above. /�
,�Qq2 ?Volltle5' —6101(C�in.d 4fti) //v.r/14.„ / 1)vi siA ,a! ',?,%, 1.
Name Title or Authority
1! /7/03
Signature L Date
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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.)
a84 S 7141.leg_ I 3,A7L �ivt s,a.q /2 /e4?
Type or Print Na , Title or Authority
1//77/23
Signature Date
I, rrcn i- Sltcid ucft , a Notary Public of the County of Licks
State of North Carolina, hereby certifies that PI e ' f;'..Sten 56—k
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 -U 0( br - , a2
GRANT SHADDUCK T
NOTARY PUBLIC �_
Wake County Notary Public
S al North Carolina
My Commission Expires June 14,2028
- My commission expires 3c,'"� / L ZOTl
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

CARY
— NORTH CAROLINA
Stormwater Division
Grading Permit Application
Prior to beginning land disturbing activities as defined by Section 3.13 of Cary's Land Development
Ordinance within Cary's jurisdiction, a grading permit must be obtained. Any required State and/or
Federal permits must be obtained prior to obtaining a grading permit. To apply for the permit, the
following information must be submitted. The permit fee is due at the time of permit issuance.
Required Information for Grading Permit Approval
(AN INCOMPLETE APPLICATION WILL BE RETURNED TO APPLICANT)
1. X Financial Responsibility Form
2. X Certificate of Insurance (for Grading Contractor)
3. X Copy of the current Deed of Ownership
4. TYPE OF PROJECT:
❑ Single Family Residence
.4 Residential Site
❑ Commercial Site
❑ Other
5. DENUDED AREA (acres) 6.82
Grading Permit Fee Per Denuded Acre=$500.00
NAME OF PROJECT Carpenters Pointe Phase 3
PROJECT LOCATION 6920 Indian Wells Road
DEVELOPMENT PROJECT# 21-DP-3285-C
PROPERTY OWNER NAME Beazer Homes, LLC-Raleigh
MAILING ADDRESS 801 Corporate Drive, Suite 330, Raleigh, NC 27607
PHONE [phone]
GRADING CONTRACTOR Wellons Construction, LLC
MAILING ADDRESS 510 N Powell Ave, Dunn, NC 28334
PHONE [phone]
FAX
I HEREBY CERTIFY that the above information is correct to the best of my knowledge and the grading
will conform to applicable ordinances. I further agree to indemnify and save harmless Cary from any
liability damages or losses resulting directly or indirectly from the land disturbing activities described
hereon. I acknowledge that violation of erosion control regulations will result in civil penalties of up to
$5000 per day.
Beazer Homes, LLC -Raleigh (Trevor Dalton) mil- ZZM 7/7/23 828-371-1907
Applicant's Name Signature Date Phone#
(please print)
CARY
316 North Academy Street•Cary, NC 27513 • PO Box 8005•Cary, NC 27512-8005
tel [phone]•fax [phone]•www.carync.gov