NCC223193_FRO Submitted_20220912

(EE
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: Ascend Brightleaf Casitas
2. Road location of land -disturbing activity: Copperleaf Parkway
Tax Map - Block - Parcel: 203363
Tax Map - Block - Parcel: 211393
Tax Map - Block - Parcel: 211392
Tax Map - Block - Parcel: 164913
Tax Map - Block - Parcel: 211388
Tax Map - Block - Parcel: 164916
Tax Map - Block - Parcel: 164914
PIN:0759-19-11-6729
PIN: 0759-18-98-6527
PIN: 0759-18-27-6012
PIN:0759-18-69-7307
PIN: 0759-28-37-3743
PIN: 0759-18-98-2417
PIN:0759-18-87-2472
3. Square footage of land to be disturbed or uncovered: 631,620 square feet (14.50 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):
DHIC-Brightleaf Casitas, LLC
Name
1341 Horton Circle
Address
Arlington TX 76011-4310
City State Zip
[phone]
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.
DHIC-BrightleaL LLC
Name
1341 Horton Circle
Address
Arlington TX 76011-4310
City State Zip
[phone]
Telephone Fax Email
201 E. Main St, 5t' Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durham.nc.us/ceng

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 parry:
■ 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.
■ 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:
CT Corporation System
Name
160 Mine Lake Ct Suite 200
Street Address
Raleigh NC 27615
City State ,Zip
919-944-4780
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.
_June 13", 2022 Elam Hall
Date Type or Print Name
704-516-1177 Vice President
Telephone Fax Title or Authority
Email
I, (64W25 , a Notary Public of the County of
State of �� , hereby certify that Xf 1 r,h 1`k 1 t
personally came before me this day and acknowledged that he is _ ye c es, m1..,4-
-
of 121-i'V +,vn.f cs :4 , LLC and acknowledged, on behalf of 17 4 I C -- 9 , d G,�1e ., Y0
, the due execution of the foregc
Witness my hand and official seal, this F '1 day of
f Notary
My commission expires L "i 202-Z
Individual Applicant
I,
State
a Notary Public of the County of
hereby certify that
instrument.
20ZZ
S. ELAINE HU�D+SPETH
NotBrit• �*q�iG****a*�**** **�***a
North Carolina
Forsyth County
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
My commission expires
20
Notary Public
LAND DISTURBING PERNUTS 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.
June 131b 2022 Elam Hall
Date Type or Print Name
704-516-1177 Vice President
Telephone Fax Title o Ant ority
REHall drhorton.com ,..
Email Signature
v v - v 4 - 111a Notary Public of the County of �—M4 -
State of hereby certify that fz. 'PA" H11
personally came before me this day and acknowledged that he is _ Vice- Prts e #(c,-,f
of DHT ;9: ti and acknowledged, on behalf of DI# c- 8,,; Lt-le—f C"-j fA s, LC.0
Witness my hand and official seal, this
the duere execution of the fore— <-( day of
My commission expires L 202-2
Individual Landowner
1,
State
a Notary Public of the County of
hereby certify that
instrument.
2022-
S. ELAINE HUDSPETH
North Carolina
Forsvth Count
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
20
day of , 20
Notary Public
5E-03 Rev.07106