NCC231573_FRO Submitted_20230523

DURHAM JCN COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
BE0 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
•• 1881••
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: Falls Village Extension: Yes or No
2. Road location of land-disturbing activity: Baptist Road(NCSR 1807)and US HWY 98
Tax Map-Block-Parcel: 193792, 193791, 193783, 193782, 193775, 193780
PIN:0861-04-53-3148,0861-04-60-8919. 0861-04-61-4693,0861-04-61-8325, 0861-04-63-6544, 0861-04-72-2680. 0861-04-72-9872. 0861-04-73-0206,
0861-04-73-2911,0871-03-03-9365
0861-03-32-9117.0861-03-43-4711,0861-03-92-2893,0861-03-93-7302,0861-04-51-9677.0861-04-53-1436
3. Square footage of land to be disturbed or uncovered 96 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):
Stanley Martin Homes LLC
Name
4020 Westchase BLD Suite 470
Address
Raleigh NC 27607
City State Zip
919.724.0624 KetchemBK(n�stanleymartin.com
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.
Stanley Martin Homes LLC
Name
4020 Westchase BLD Suite 470
Street Address
Raleigh NC 27607
City State Zip
919.724.0624 KetchemBKWstanleymartin.com
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.
201 E.Main St,5'Floor,Durham,N.C.27701•[phone]•Fax[phone]
www.co.durham.nc.us/ceng

• Inspect,maintain and repair sedimentation and erosion control measures,especially after rainfall events.
• Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Stanley Martin Homes LLC
4020 Westchase BLD Suite 470
Raleigh NC 27607
919.724.0624 KetchemBK@?stanleymartin.com
Telephone Fax 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.
Brian Ketchem
Date Type or Print Name
919.724.0624 Director of Land Development
Telephone Fax itle or
KetchemBK a Stanle vMartin.com
Email Signature
***********************************************************************************************************************************
Business Applicant(Provide corporate resolution on signatory authority)
I, _(1(A\_/v I C ,a Notary Public of the County of
State of I v ( ,hereby certify that (. v)air\ VYI
personally came before me this day and acknowledged that he is V1 rt.Lf-or \i-e\ok r(---
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of S\ik �fL YVp 4(1 t -kS nand acknowledged,on behalf of e„ 1-tt•.1 4,0y1A,L0 La.
,the due execution of the foregoing instrument.
Witness my hand and official seal,this day of /y ,�2�0-7-3
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Nota 'ublic
My commission expires C (kW\Off LA ,20 "L3
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Individual Applicant -?� �`y Coob �2"�' v
I, ,a Notary Public of the County ofH � Q.•�
•
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.
Brian Ketchem
Date Type or Print Name
919.724.0624 Director of Land Development
Telephone Fax pie or Authority
KetchemBK a'StanlevMartin.com
Email Si re
Business Landowner(Provide corporate resolution on signatory authority)
'O--V--- ,a Notary Public of the W
!County of
State of 1f\I ,hereby certify that 671 IXV\
personally came before me this day and acknowledged that he is r\f C' ' t.€ , t �� �L " ' - 1/1
of c& l.P.Aq (..Card acknowledged,on behalf of -'' 6"y\! 0.0'WI,io LLC
,the due execution of the foregoing instrument.
Witness my hand and official seal,this 1 L 5 day of INA(�J�, ,20 22
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Not Public ,`• public
My commission expires �- i ,20 Z•'3 , Notary
Woke
County
?,. 12-04.2023 =Q
Individual Landowner '�, p \,`�
I, ,a Notary Public of the County of > /,q �'C+AA�\`\
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.07/06