NCC232391_FRO Submitted_20230810

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.rt:7T Durham City/County (Office Use Only)
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a Sedimentation and Erosion Control
EitFINANCIAL 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: Carolyn Drive Extension: Yes or No
2. Road location of land-disturbing activity: 657 Miami Blvd
Tax Map-Block-Parcel: PIN: 0841-30-77.7360
3. Square footage of land to be disturbed or uncovered: 372,002 sf(8.54 ac.)
4. List below the landowner of record. Each landowner must complete Item S.
(If there are multiple owners,please list on a separate page):
GFGS NORTHSTAR, LLC
Name 8601 SIX FORKS RD STE 270
Address
RALEIGH NC 27615
City [phone] State Zip [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.
GFGS NORTHSTAR, LLC
Name
UAW'
pSIIXXreFORKS RD STE 270
RAfLEIGH ss NC 27615
(i19 830-2670 State Zip
t ) [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.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
201 E.Main St,5°i Floor,Durham,INC.27701 •[phone]•Fax[phone]
www.co.durham.ne.usiceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Paracorp Inc
Name 176 Mine Lake Ct#100
Street Address
Raleigh NC 27615
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: (I)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.
q- _ aoa3 Yang Song
Date Type or Print Name
[phone] Manager
Telephone Fax Title or Authority
[e-mail]
Email Signature
*****************4*******************9********************************4**P**4*4*********************************4****4******9******
Business Applicant(Provide corporate resolution on signatory authority)
1, lAlri&4le 14. )S-Ve.eM ,a Notary Public of the County of Wffe
State of►onit-N li1Flr2AuAf A ,hereby certify that Yang Song
personally came before me this day and acknowledged that he is Manager
of GFGS NORTHSTAR, Ilc and acknowledged,on behalf of GFGS NORTHSTAR, LLC
,the due execution of the foregoing instrument.
Witness my hand and official seal,this day of FrPR1 L ,20 i3
Notary Public
My commission expires w i II ,20 a 3 ^ KRIST+�*LE H. OSyT�EEN
******************************************************************************************** ******�1�9riT Ust*Ild**a:**x
Individual Applicant WAKE COUNTY, N.C.
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.
u-5„ YANG SONG
(RA 830-2670 Type or Print Name
Manager
Telephone Fax Title or Authori
[e-mail] `T
Email Signature
Business Landowner(Provide corporate resolution on signatory authority)
1, k i c 1 t 14. 04Yt rrr, ,a Notary Public of the County of kg
State of t.)0z(v C41.400 q)A ,hereby certify that YANG SONG
personally came before me this day and acknowledged that he is Manager •
of GFGS NORTHSTAR, LLC and acknowledged,on behalf of GFGS NORTHSTAR, LLC
,the due execution of the foregoing instrument.
Witness my hand and official seal,this $�( day of l' EIL 20 R,3
Notary Public
My commission expires S td l 9 ,20 al . • KRISTLE H. ° TEEN
Individual Landowner WAKE COUNTY, N.C.
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