NCC232716_FRO Submitted_20230911

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
E0
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
• 18817
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: Durham Charter Extension: Yes or No
2. Road location of land-disturbing activity: 5510 Wake Forest Hwy.Durham,NC 27703
Tax Map-Block-Parcel: 193738 PIN:0860-79-66-3257
3. Square footage of land to be disturbed or uncovered: 1,245,492(28.6 AC)
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
HEALTHY START EDUCATION,INC
Name
6817 Huntingridge Road
Address
Chapel Hill North Carolina 27517
City State Zip
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.
HEAD 71r'1 Siex Epuc.t .,ri c , .
Name
e i 1 O C.1-\AP L H
Street Address
DUCA-4AM N.c -1—)of
City State Zip
0119 aa51a,00 qlq (I e) ox1 1__J2 c...or-4
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 cnndi,rt all-land-disturrbing activity 30 as to prevent off-site sediinetitation.
201 E.Main St,56 Floor,Durham,N.C.27701•[phone]•Fax[phone]
www.co.durbam.nc.usiceag

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
1-k-br;c1- („�,4ra.c-1 i 'r.,t.
Name c341
rnefsii (s "IC.-fie 1JY. (k, I a
Strutkd{es \ 0 C_
tate
C`715-4f/l-61fr i5 Sgii- i{?/- (ci' Zip 5fccc_24414....10",c1, r cd- •ce,,,-%
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.
(a -/S- 013 57Lcr / r;CA
Date_ Ty or Print N e
v,-q -a8ss qM-y7l-6ryo rrto,'
Telephone Fax Title or Auth ' i�✓�" `---
_S - el- hir;el, ,:. , C -
Email Signature
Business Applicant(Provide corporate resolution on signatory authority)
I, ` �' ,,�.�-s °'a Notary Public of the County of ���-�—'
State of ii/h �•o J^'` ,hereby certify that S/ `tit /,/,
personally came before me this day and acknowledged that he is �/r-si��-•-/".'
of//6r�v2 7;"7`irr�'7/apnd acknowled �i �„ .ram ged,on behalfof ���ri -'4'Hf//'C
,the due execution of the foregoing instrument.
5mgrtylekmdiffod official seal,this S day of �'�� 20 13
NOTARY PUBLIC
Durham County �/'___ .�i-1��
North Carolina Notary ublic r c Pew5 � 24. ,20 ?3
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.
CD' I5- a3 Liz MCeEI
Date Type or Print Name
Iq aa- laoc. qlq lo'666 q oaf 13oAC.1) CH R 1-
Telephone Fax pY 'Title Authority
Llztm NQ2�t . �
Email e
Business Landowner(Provide corporate resolution on signatory authority)I, A rah d.&t M� �-�"{ I( ,a Notary Public of the County of 0 �cu ji a kW
State of 00 r f h /�(,r 0 It 11 t ,hereby certify that e-I I.
z. ( 6 e‘f h 6 . Morey
she � '^ /
personally came before me this day and acknowledged that•he is e, 1 Q&r d, l�l to r'
of 14011114iy Sfax F Ed. L h t'rJ �•land ac owledged,on behalf of 1-IecLt' Start- eetilLg_7L
lQ
,the due execution of the foregoing
•
1 Jr-+-ti day of 20 Iwo nnttnw��',''
Witness my hand and official seal,this jg A M. y
$ O
_
otary Public
�p V�Wlbe r 3D 20 a25 a
My commission expires
Individual Landowner '�,q <y a+=
I, ,a Notary Public of the County of yt Mt,C,�tttt ,
State of ,hereby certify that
personally appeared before me this date and under oath acknowledged that the above foil 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

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