NCC230964_FRO Submitted_20230404

DURHAM JCN
COUNTY Durham City/County
(Office Use Only)
BE
Sedimentation and Erosion Control
FINANCIAL RESPONSIBI
LITY/OWNERSHIP FORM
,�,1881 * WITH LANDOWNER CONSENT FORM
No person may initiate any land-disturbing activity covered by the Durham City-County Unified Development Ordinance before a
Land Disturbing Permit is issued by the Sedimentation and Erosion Control Office. Issuance of a Land Disturbing Permit does not
relieve the permittee of the obligation to obtain any other licenses, permits and approvals as may be required by Federal, State,
County or Municipal governments. This office must be notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name: Ellis Road Storage Center
2. Road location of land-disturbing activity: 2104 & 2112 Ellis Road
Tax Map-Block-Parcel: 1 63349/1 63348 PIN: 0749-01-26-0407/0749-01-26-1410
3. Square footage of land to be disturbed or uncovered: 148,456 sf (3.41 acres)
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
'Po wtre_cQ Pto act-ty LLC,
Name �J /�
Z 31 O S . :CLk.`, Val J£ -i-t, Z3$
Address
"Da.r.,_ ia- z77o3
City State Zip
239— 4SZ $S3 Z Mei ss re.r s b.o k st. ca✓1'1
Telephone Fax Email
5. List the person or entity financially responsible for this land-disturbing activity: The financially responsible party shall
be (1) the developer or other person who has or holds themselves as having financial or operational control over the land-
disturbing activity and/or(2)the land owner or person in possession or control of the land when they have directly or indirectly
allowed the land-disturbing activity or have benefited from it and (3)the named party on the Land Disturbing Permit.
Stackhouse Development LLC
Name
2310 Miami Blvd Suite 238
Street Address
Durham NC 27703
CityZip
State
317-339-8302 [e-mail]
Telephone Fax Email
The Sedimentation and Pollution Control Act(Act)and the Durham City-County Unified Development Ordinance(Ordinance)
includes, but is not limited to,the following legal obligations of the financially responsible party:
• Maintain a set of approved sedimentation and erosion control plans, if required,on site.
• Display permit on site.
• Understand and implement any required plan, including the construction sequence and details.
• Inspect,maintain and repair sedimentation and erosion control measures,especially after rainfall events.
• Refer to Section 12.10.4B of the Durham City/County UDO for groundcover time line requirements.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
120 E.Parrish Street, Law Bldg., 151 Floor,Durham,N.C.27701 •[phone]• Fax[phone]
www.dconc.gov/index.aspx?page=180

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
-Janes E3-t�e5 TA- 5ervt es LLC
Name
2310 Miami Blvd Suite 238
Street Address
Durham NC 27703
City State
25.z LiS 853 Zip
Telephone Fax ' I ' a� 1en�S�E/G�ioecsQ. Co/It
Email
7. The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath. I
understand that the person or entity listed on Line 5 above will be: (1)the owner of the Land Disturbing Permit when issued;
(2)responsible for ensuring compliance with the Act and Ordinance; and, (3)will be the only person or entity with standing to
appeal any action taken or decision made by the Sedimentation and Erosion Control Office.
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Date
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Telephone Fax Title o Nho.it� -7/
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S$A l&1 4,,rrn4 540 - �►kse. Co.
Email Si `
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Business Applicant(Provide corporate resolution on signatory authority)
1, lj l' ,a Notary Public of the County of u
State of A./ - ,hereby certify that •,I1,430 on
personally came before me this day and acknowledged that he is At 4)
I�A V +0-
of 75 on P\4 5eyi nd acknowledged,on behalf of
3(hv; Si:.4 vI p,� 2-LC.,the due execution of the foregoing instrument.
Witness my hand and official seal,this If day of Jp. beta y ,20 2�2
Notary Public
My commission expires y t` �I1,At,.f- ;I ,202,,E , r
J TYLER HOWARD
********************************************************************************************.**** R;:0f *WMAW *P9WMP
Wake County
Individual Applicant My Commission Expires
August31,2026
I,
,a Notary Public of the County of
State of , hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal,this day of ,20
Notary Public
My commission expires 20
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner, I provide my consent for land-disturbing activities to occur on the property listed in
Item 2 by the person or entity listed in Item 5.
Date 2,l - /-¢7T0^, C .� G J�e.L✓
7I _f l3 ^o a o Type or Print Name
/n ly?i-G e—
Telephone Fax Title r Aut ty
''`�� \;33aa) ran a cw.St,CpM C
Email Sign ure
Business Landowner(Provide corporate resolution on signatory authority)
I, 4,\;5i ._ Sn>0(4.D( ,a Notary Public of the County of IA)Ole
State of 10 C , hereby certify that NO-t r% C. A,n -Sat,
personally came before me this day and acknowledged that he is an .er
of f�"oul.eregn( Prtl�
�-l.t✓ and acknowledged,on behalf of 6wcre¢ �� � L)►
,the due execution of the foregoing instrument.
Witness my hand an41 official seal this • day of C 20 7-7i
Mellon Solomon
NOTARY PUBLIC
Woke County Notary
Mycommission expnq� No Carolina ry Pu
tamnwssion Erns March 30,2025 I-,20
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Individual Landowner
I, ,a Notary Public of the County of
State of ,hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal,this day of 20
Notary Public
My commission expires 20
SE-03
Rev. 10/13