NCC223141_FRO Submitted_20220906

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. Project name: Lot 14 Colvard Farms Phase 10
2. Road location of land -disturbing activity: 415 Pond Path
Tax Map - Block - Parcel: 000202-000215-227303
3. Square footage of land to be disturbed or uncovered: 29,924
PIN: 0717-32-60-1277
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
see pages 4 and 5
Name
Address
City State Zip
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.
Tripp Loyd Builders, LLC
Name
2501 Reliance Ave
Street Address
Apex NC 27539
City State Zip
[phone] [phone] [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, 5" 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:
Frank R Loyd, III
Name
2501 Reliance Ave
Street Address
Apex NC 27539
City State Zip
[phone] [phone] [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.
Jwl a'r aoa a- Frank R Loyd, III
Date Type or Print Name
[phone] Manager
Telephone
Builders.com
Fax
Email ftnat ke
Business Applicant (Provide corporate resolution on signatory authority) N 0 TA' R Y 2Z
I, 2l'l V7 L Ha ✓-fma nn a Notary Public of the County of Wake = w Cw"ksp„zExpires
State of North Carolina hereby certify that Frank R Loyd, III PUBLIC
personally came before me this day and acknowledged that he is Manager
of Tripp Loyd Builders, LLC and acknowledged, on behalf of Tripp Loyd Builders, LLC
the due execution of the foregoing instrument.
Witness my hand and official seal, this / Sr
` day of J I l ,L / (/ , 20
�l- �!� �y�� 20� Notary Public
My commission expires _e�.
Individual Applicant
I, , a Notary Public of the County of
State
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,
My commission expires
day of
Notary Public
20
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.
see pages 4 and 5
Date Type or Print Name
Telephone Fax Title or Authority
Email Signature
Business Landowner (Provide corporate resolution on siEnatory authori
I, , 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 20
Individual Landowner
20
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 120
Notary Public
My commission expires 20,
SE-03 Rev.07/06

4. List below the landowners of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Sanjay Daluvoy
Name
311 South Bend Drive
Address
Durham NC
27713
City State
Zip
[phone]
[e-mail]
Telephone Fax
Email
Melissa Daluvoy
Name
311 South Bend Drive
Address
Durham NC 27713
City State Zip
[phone] missydaluvoy(a-)gmail.com
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.
l (L VD, aoa a
Sanjay Daluvoy
Date U
Type or Print Name
[phone]
Landowner
Telephone Fax
Title or Authority
[e-mail]
Email
Siinat
Individual Landowner
I, U� 0 L {—�g yli ft o a Notary Public of the County of Wake
State of North Carolina hereby certify that Sanjay Daluvoy
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 aDl`'"� day of li l
20 ./
Notary Public HART
/ ti '.
My commission expires `l, r 20 d,6 0 7 A R r y
�� PUBLIC G�

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.
Melissa Daluvoy
Date Q J Type or Print Name
[phone] Landowner
Telephone Fax Tittle or Authority
[e-mail] v U /
Email Signature.
Individual Landowner
I, �r m L-tkaV{ uaw a Notary Public of the County of Wake
State of NC hereby certify that Melissa Daluvoy
personally appeared before me this date and under oath acknowledged that tt}e the form was executed by them
Witness my hand and official seal, this a0W day of �/ (t
20 -)-a
Notary Public
My commission expires //`
HART,',
20_4�NOTARyCmwdulm ?Z
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PUBLIC
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