NCC215862_FRO Submitted_20211021

DURHAM
COUNTY
Nc
• 18a1
Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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: Tredenham
2. Road location of land -disturbing activity: 5607 Leesville Road
Tax Map - Block - Parcel:
193299, 193295
3. Square footage of land to be disturbed or uncovered:
PIN:076901172927,076901089120
14 Acres = 609,840 SF
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
TRI POINTE HOMES HOLDINGS, INC.
Name
1330 SUNDAY DRIVE, SUITE 101
Address
RALEIGH NC
City State
919-675-8822
27607
Zip
BOB. [e-mail]
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.
Bob Davenport
Name
1330 Sunday Drive, Suite 101
Street Address
Raleigh NC 27607
City State Zip
919-675_ -8822 _ bob. davenportgLtriipointehomesxom
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.
■ Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
201 E. Main St, 5t' Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durham.nc.us/ceng

■ 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:
ri Poi,1-6 l 01ne ."r
Name —
l3o Sg►o?P't.
Street A •ess
/VG .2 ��d 7
Ciry 9(f r �p2 State Zip 64.
!. ela
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,
26-2, r Rah p v&'X 'r�-
Date Ty e or Print Na e
Telephone Fax Title o ri
[ b6. c%c E ' r►.cf : (�A.
Email Signature
Business Applicant (Provide corporate resolution on sianatory authori
I, :. ,d / : _ Sr a Notary Public of the County of W A k E
State of N c' hereby certify that
personally came before me this day and acknowledged that he is
of _ �a�L _ and acknowledged, on behalf of *rr:
Witness my hand and official seal, this
the due execution of the foregoing instrument.
day of I -it 20
Notary Public
My commission expires a 1 i f 20 23 .
Individual Applicant
I,
State
a Notary Public of the County 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
Michael J Atkins, rAND DIS'I
NOTARY PUBLI
Wake County, NC
My Commission Expires December 19, 2023
day of _,20.
Notary Public
20
PERMITS ARE NON -TRANSFERABLE

Provide a Notarized Item $ for each landowner listed in Item 4.
S. 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 Type or Print Name
Email
Fax Title
Signature
Business Landowner (Provide corporate resolution on sianatory authori
I, A&L&d 5 7-, a Notary Public of the County of W Alt,
State of N , hereby certify that
personally came before me this day and acknowledged that he is bivis :1 ft Pn r;4 r
IMMt
of (.&;I and acknowledged, on behalf of Sri p.irlt
Witness my hand and official seal, this
the due execution of the foregoing instrument.
2.A
My commission expires 14 ( If 2093
Individual Landowner
I,
State
day of Aen'1 20 Ll
f
-P A r gt�_ r�
Notary Public
a Notary Public of the County 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.
My commission expires
day of
Notary Public
20
20
SE-03 Rev.07l06
Michael J Atkins, Jr
NOTARY PUBLIC
Wake County, NC
My Commission Expires December 19, 2023

4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Name
Address
City State Zip
Telephone Fax Email
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
Type or Print Name
Telephone Fax Title or Authority
Email Signature
Business Landowner (Provide coruorate resolution on sienatory authori
1, a Notary Public of the County of
State of hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of
Notary Public
My commission expires 120
Individual Landowner
I, , a Notary Public of the County of
State of
hereby certify that
20
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 120
Notary Public
My commission expires 20