NCC230161_FRO Submitted_20230120

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: Olive Branch Offsite Roadway Improvments T�
2. Road location of land -disturbing activity: NC98 (Lat. 35.975751228881705, Long.-78.78598546981812)
Tax Map - Block - Parcel: nla, linear transportation oroiect PIN: 0861-03-30-3730
3. Square footage of land to be disturbed or uncovered: 0.94ac
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Pulte Home Companv. LLC
Name
1225 Crescent Green Drive, Suite 250
Address
Cary N C
27518
City State
Zip
919-816-1146 nla
chris.raughlevCcDpultegroup.com
_
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.
Pulte Home Companv, LLC
Name
1225 Crescent Green Drive Suite 250
Street Address
City State Zip
919-816-1146 nla chris.rau hie ulte rou .com
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, 511 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:
Name
Street Address
City State Zip
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 hand 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.
7 2 S 2 2 Chris Rau hle
Date Type or Print Name
9 Ot VP Land Development
Telephone Fax Title or Auth
C. In r i s . r OL" w�% l cv C.J _ u
Email COriI Signature
Business Aaplicant (Provide corporate resolution on sianatory authori
I, AA Qa i$ a Notary Public of the County of _
State of /V L hereby certify that 6/0 Vj
personally came before me this day and acknowledged that he is 1'
of /VJ�P(ltrl'l�i `and acknowledged, on behalf of An le,
C,0 /V1V (A j ii the due execution of the foregoing instrument.
Witness my hand and o ficial seal, this V57 day of c} , 20 �-
�} Notary Public
My commission expires �1 J v�.�C� 20.
Individual Applicant
T,
State of
a Notary Public of the County of
hereby certify that
""'Eflllkll!!
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
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.
Chris Raughley
Date Type or Print Name
VP Land Development
Telephone Fax Title or Authority
Email
Signature
Business Landowner rovide corporate resolution on si nata authority)
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
1, , a Notary Public of the County of
20
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
My commission expires
20
day of , 20
Notary Public
S E-03 ttev.07/06