NCC240533_FRO Submitted_20240223

C,*.RY
A
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: Alston Town Center-Phase 1C Infrastructure
PROJECT DEVELOPMENT PLAN #: 22-DP-1332
PROJECT LOCATION:
0735395493,0735490086,0735383886,0735493416
Property Tax ID#/PIN
0 NC-55 Hwy, Cary, North Carolina 27519
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: 01/02/2024
ACREAGE OF LAND TO BE DISTURBED: 17.35 acres
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
Cary Creek Land, 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.)
Cary Creek Land, LLC
Name(Person or Firm)
5950 Fairview Road,Suite 800
Street Address(No PO Box)
Charlotte, NC 28210
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

704.295.4005
Telephone Number
704.295.4059
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.)
Chuck Handy
Name
5950 Fairview Road,Suite 800
Street Address(No PO Box)
Charlotte, NC 28210
City State Zip
704.295.4000
Telephone Number
704.295.4059
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.
Paul Herndon OR
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
Cary Creek Land, LLC
Name(Person or Firm)
0735395493,0735490086,0735383886,0735493416
Property Tax ID#/PIN
5950 Fairview Road,Suite 800
Street Address(No PO Box)
Charlotte, NC 28210
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 planned land-disturbing activities on the property listed in Section 1 above.
Chuck Handy V P
Name Title or Authority
December 15, 2023
Signature Date
[e-mail] 704.295.4000
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.)
eI A-a c_ -'S M, � .._ V ,P
Type or Print Name Title orAuthonty
Signature � Date
,a Notary Public of the County of
State of North Carolina, hereby certifies that 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, l`:1T\f) day of NCP..Y1h2•�' , 2023
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lwar M. Noa h
,, U: Notary Public
•.,�e Pkg.‘" My commission expires 1� X-s.
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into-
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