NCC221906_FRO Submitted_20220519

Financial Responsibility Ownership ENGINEERING
p Y p �:
(Sedimentation Pollution Control Act) - SERVICES
One Exchange Plaza, Suite 304
Raleigh, NC 27601
This section to be completed by Cit of Raleigh staff
Submittal Date
Effective Date
Transaction Number
Permit Number LD-
sections to be completed by the
SECTION 1: GENERAL INFORMATION & INSTRUCTIONS I
This form is required to be completed, notarized and submitted with all Land Disturbing Permit applications. The
information provided herein becomes an enforceable part of the approved Erosion and Sediment Control Plan
and the Land Disturbing Permit listed above. Non-compliance may result in the assessment of civil penalties
and could potentially affect all permits, inspections and/or Certificates of Occupancy for this Project. Should any
of the information on this form change, a revised, executed form shall be submitted within thirty (30) days, said
submission shall include a copy of any documents recorded with the Register of Deeds.
The effective date of this form shall be the effective date as designated above by the City of Raleigh. No rights
and liabilities associated with any designation shall incur until the effective date, or the effective date of transfer
to any subsequent Party. Upon any delegation of an Applicant/Permittee or Financially Responsible Party, the
Owner shall continue to receive notice at the address provided.
A permit may not be transferred to a residential Home Owner's Association as the Applicant/Permittee or
Financially Responsible Party, until the issued Land Disturbing Permit for this project is administratively closed
by the Stormwater Management Division.
Raleigh City Code §14-1011 sets forth that it shall be unlawful and a violation of this code for any person to give
false information or misrepresentations in any application or permit required by this code. Failure to provide full
disclosure of the requested information may be grounds for denial or revocation of a Land Disturbing Permit.
Please complete all sections below. Type or print and, if information on the form is not applicable, place N/A in
the blank. All pages of this form must be completed and submitted or the form will be rejected and returned.
The property owner must initial each page of the form prior to submittal.
SECTION 2:
PROJECT INFORMATION
PROJECT NAME
Piedmont Point
PERMITTED PHASE(S)
1
PROJECT ADDRESS
2018 Seneca Drive, Raleigh, North Carolina 27604
WAKE OTY PARCEL ID
NUMBER(S)
1724-39-5281, 1724-39-84795 1724-39-8291
ANTICIPATED DATE OF
PROJECT INITIATION
L L
091202
EXPECTED DURATION OF
PROJECT
0
912026
ACREAGE OF LAND TO BE
DISTURBED
�
1 Acres
PROPERTY OWNER'S INITIALS' Storina,crter Inspections Form 112
0801.16
Page 1 of'5

SECTION 5: FINANCIALLY RESPONSIBLE PARTY INFORMATION
The Owner of the subject property authorizes the following person or firm as the Financially Responsible Party
for this Land Disturbing Permit. The Financial Responsible Party shall receive service of any notice, process,
civil assessment or pleading in any action or legal proceeding arising out of any matter relating to the Land
Disturbing Permit issued under this permit application and Unified Development Ordinance, Article 9.4.
Andy Crawford Vice President
FINANCIALLY RESPONSIBLE PARTY TITLE
Eastwood Homes of Raleigh, LLC 919-758-8208 9/g- y27-z96z
COMPANY, IF APPLICABLE TELEPHONE NUMBER
6601 Six Forks Rd. Suite 100
STREET ADDRESS (NO P.O. BOX) FAX NUMBER
Raleigh, NC 27615 acrawford@eastwood homes, com
CITY, STATE, ZIP E-MAIL ADDRESS
The undersigned acknowledges that he is the Financially Responsible Party for permit implementation,
compliance and enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance,
Article 9.4. He has read and understands the statements and disclosures made in this form, that the information
disclosed herein is true and correct to the best of his knowledge and belief.
This form must be signed by the person or firm financially responsible for the land developing activity or other
person with authority to execute instruments for the financially responsible party, if not an individual.
This, the 7 day of Ap�� 20 2 z
vice--
FINAN ALLY RESP SIBLE PARTY SIGNATURE TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this
day of C . !( 20 aQ
L
o ary Public (print I
ame) y Public Si
My Commission Expires:
Notary Public Title 1
—
` (SEAL)
PROPERTY OWNER'S INITIAL& �C Stormwater Inspections Form 112
08.2116
Page 4 of 5

SECTION 3: PROPERTY OWNER INFORMATION
Eastwood Homes of Raleigh, LLC
PROPERTY OWNER OF RECORD f/y— y27 —2g6Z
6601 Six Forks Rd. Suite 100 919-758-8208
MAILING ADDRESS (NO P.O. BOX) TELEPHONE NUMBER FAX NUMBER
Raleigh, NC 27615
CITY, STATE, ZIP
[e-mail]
E-MAIL ADDRESS
The undersigned acknowledges that he is the Owner, or holds the Owner's power of attorney, of the property
which is the subject of this application, and further states that the permitted land -disturbing activities are
authorized to be conducted on the subject property with the full knowledge, permission and consent of the
Owner.
The undersigned acknowledges that he is the Property Owner for permit implementation, compliance and
enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance, Article 9.4, The
Owner of the property upon which the land -disturbing activity is to be undertaken states and affirms that he has
read and understands the statements and disclosures made in this form and that the information disclosed
herein is true and correct to the best of his knowledge and belief.
This form must be signed by the Owner of the property or by a person with authority to execute instruments, if
the Owner is not an individual.
This, the 7 If*day of fn 17f-/l , 2o2Z .
PROP.LeRTY OWNER SIGNATURE
TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this
L_day of �Ik 20.
Notary Public (pri(yame)
My Commission Expires: -
Not. r
MY co Qkp p(,bl"C
Z _S:{O�ntl�
�ixprres_`
ti
It,tt r
PROPERTY OWNER'S rN[TLUS, fe
(SEAL)
Stoanwater Inspections Form 112
U8. 23.16
Page 2 oj5