NCC231323_FRO Submitted_20230505

DURHA JCN
COUNT ODINc 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 Glen
2. Road location of land-disturbing activity: Olive Branch Road and Doc Nichols Road
TaxMap-Block-Parcel: 193374 PIN: 0860-35-17-4592
3. Square footage of land to be disturbed or uncovered: 1, 229, 781 SF
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
KB Home Raleigh—Durham, Inc .
Name
4506 South Miami Blvd. , Suite 100
Address
Durham NC 27703
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.
KB Home Raleigh—Durham, Inc .
Name
4506 South Miami Blvd. , Suite 100
Street Address
Durham NC 27703
City State Zip
[phone]
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,5th 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 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.
May 1, 2023 R. Scott Johnson
Date 919-4 2 2-8 6 0 6 Type or Print Name
Sr . Director of Land Development
Telephone Fax Title(:1791th 'ty
rsjohnson@kbhome . com
Email Signature /
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Business Applicant(Provide corporate resolution on signatory authority)
I, O.C% Gl Ca vel Lm V ,a Notary Public of the County of WA 1
State of N D M 4h Carat In Cn ,hereby certify that R. SGO f f J o h n ' r-
personally came before me this day and acknowledged that he is SC. Q lYafD r
of LA n 01 be I d J)yy)c o+ and acknowledged,on behalf of
N d►'Y)G R a k .r bu Int .
a m ,the due execution of the foregoing instrument.
Witness my hand and official seal,this I S+ M day ofG y ,20 Z
RCHEL , North
CAVALEAR /�.A . C� Q,l�
NotaryPublic, North Carolina __ 11
W ke County Notary Public
My commisl�ion ei YrEs tsti 02�' res 20 17
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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.
May 1, 2023 R. Scott Johnson
Date Type or Prixrt Name
919-422-8606 Hr . Director of Land Development
Telephone Fax Tit i3AuthDtty
rsjohnson@kbhome . com
Email Signature
ofr Business Landowner(Provide corporate resolution on signatory authority)
I, RQc1h t Ca va l c a r ,a Notary Public of the County of VA kG
State of North Cam li n 4- ,hereby certify that n, scoff. Ja hrmO r)
personally came before me this day and acknowledged that he is S r, D(f P C-F0 r
of Lj,nol Deve l o! m e flc and acknowledged,on behalf of K B H o W- RA k i 9 h D o r h a th Inc
,the due execution of the foregoing instrument.
Witness my hand and official seal,this I S} day of M(It/ ,20 2.3)
RACHEL CAVALEAR
Public, North Carolina
Wake Co my Notary Public
My c mmis@�iiIf@,s s i F,i r,, ,20 Z_
prill9, �27
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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.07/06