NCC231202_FRO Submitted_20230427

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
DEO Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
1881% 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 Reserve Sewer Outfall-Mill Creek Portion
2. Road location of land-disturbing activity:1607 Olive Branch Road
Tax Map-Block-Parcel: 194195,194199 PIN: 0860-72-72-4516, 0860-72-89-5462
3. Square footage of land to be disturbed or uncovered:55,539 sq ft
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
1)Dan C Dawson 2)Mary E San Filipo as individual and as trustee of William San Filipo Credit Shelter Trust
Name
1)1205 Olive Branch Road 2)1313 Olive Branch Road
Address
Durham NC 27707
City State Zip
1)919-423-7869 2)919-395-2723 1)[e-mail] 2)[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.
MCRT SFR Investments,LLC
Name
1001 Morhead Square Drive.Suite 350
Street Address
Charlotte NC 28203
City State Zip
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.
• Refer to Section 12.10.4B of the Durham City/County UDO for groundcover time line requirements.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
120 E.Parrish Street,Law Bldg.,lst Floor,Durham,N.C.27701 •[phone]•Fax[phone]
www.dconc.gov/index.aspx?page=180

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
MCRT SFR Investments,LLC
Name
1001 Morhead Square Drive.Suite 350
Street Address
Charlotte NC 28203
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 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.
Date Type or Print Name
3-4-7—(DUI G( e-rt,i V !� 1- ^�-c li` cel in/5/ /..v c c't
Telephone urp @ Fax Ti or or' -t ` tel
mur h mctrust.com
Email Signature
+******.********,*********+************************.+* ********************************************************...*x**+.*x*********
Business Applicant(Provide corporate resolution on signatory authority)
I, 5amaiMck. ,4r(o`v►so n ,a Notary Public of the County of Ga.s o r
State of N(__. ,hereby certify that LAX( I(,a(rv� k C'ens
personally came before me this day and acknowledged that he is5ent U(" t/p C� r
of LeAt/t t 1 S 1h O nS and acknowledged,on behalf of M C.�� 5 /' ,,t1111 l I?I/1,
.L r(J'2�S-hAeA�'�-$! Z-L-. ,the due execution of the foregoing instrument. ��N``'NP 4 i4 .
iro
Witness my hand and official seal,this I l day of Te6 ,20 40lArir OZ
2
Notary Public
My My commission expires 1 a-I"'as a 1 ,20 a Li. .r�9s� +�`
�f o
Individual Applicant
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 ,20
Notary Public
My commission expires 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.
Date Type or Print Name
Telephone Fax Title or Authority
[e-mail]
Email Signature
Business Landowner(Provide corporate resolution on signatory 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 ,20
Notary Public
My commission expires .20
*****************************************************************xxx_.x*****xH*****xxx_xx_xxxx*xxx***********..xxx._..xx*********
Individual Landowner
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 ,20
Notary Public
My commission expires 20
SE-03 Rev.10/13