NCC221007_FRO Submitted_20220314

JCN
Durham City/County (Office Use Only)
Sedimentation and Erosion Control
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. Projectname:Wayne and Mary Gibson Residence
2. Road location of land -disturbing activity: 7606 Kepley Road , Chapel Hill, NC 27517
Tax Map - Block - Parcel: 230783
3. Square footage of land to be disturbed or uncovered: 4.83 Acres
PIN:0707-32-57-3089
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Wayne and Mary Gibson
Name
511 Tarrytown Ctr.
Address
Rocky Mount NC 27804
City State Zip
252-458-5561 [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.
Bost Construction Co., Inc.
Name
4030 Wake Forest Road,
STE 349
Street Address
Raleigh
NC 27609
City
State Zip
919-460-1983
919-460-1986 [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.
■ Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
201 E. Main St, 5th Floor, Durham, N.C. 27701 e [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:
Rex Bost
Name
1941 Evans Road
Street Address
Cary, NC 27513
Ciry State Zip
919 460 1983 [e-mail]
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.
Rex A. Bost
Type or Print Name
919 460 1983 President, Founder
Telephone Fax Title or Ant ity
[e-mail]/�,�-'`-.-
Email
Business Applicant (Provide corporate resolution on sil4natofy authority) �t}"p"� [ry ......"'
V . C4 Y-) Y°, a Notary Public of the County of (�j �t tVV+,
State of 1iWy7r' 4 CA.,�'-C)lj 1 1,,r A., , hereby certify that J� �' � � � 0 ,-4--
personally came before me this day and acknowledged that he is
of _ and acknowledged, on behalf of
e as8[e.. `.° 4 � tj ..vld`t`ht`
, the due execution of the foregoing instrument.
Witness my hand and official seal, this lb day of ^ /CL20 2 j
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_-- _ Nota ubli
My commission expires} 20�.
Individual Applicant
I, , a Notary Public of the County of
State of , hereby certify that
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My commission expires
W
Notary Public
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.
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Date Type or Print Dame
�fY'1Y3- 9 a I a r3 -- y�f.I- s'3t-
Telephone Fax Title or
Email
Signature
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 S.
Bate Type or Print Name
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Telephone Fax Title or #,uthonty
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Email
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Individual Landowner
1, E)'EzCLbe+h 0. 4�pUji vl:5_ a Notary Public of the County of — --
State of� C all a hereby certify that E .W b 5a a
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 24 day i lbvp_A 6% - t 20 :7, 1
N ary Pu lic _
My commission expires 031 U3 A� _ 20
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Elizabeth O Robbins
NOTARY PUBLIC
Nash County, NC