NCC232808_FRO Submitted_20230919

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
13E0 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
�1881/
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: Falls Village North Extension: Yes or No
2. Road location of land-disturbing activity: 739 Baptist road,Durham NC
Tax Map-Block-Parcel: PIN: 0861-55-91-1330
3. Square footage of land to be disturbed or uncovered: 5,405,149 SF
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multi 1e owners please list onta,se crate page):
5-I WA'1 t h it��IQS W�-�
Name
ti010 W44-Ctetux. 131v8 , Swk. '��
Address
Lush NC. 21cio-j
City State Zip
L� _-11-t .CktiVA .t 1/1tim 1 @S l Moen •twin
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.
lU r,✓hrn 1.1-r mQ s ( LC,
Nob •
?o W�sitvu. .e. El / , suo>e. t•rta
Stet,Addre C_ 114 4
Ci 1 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.
• 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,5th Floor,Durham,N.C.27701 •[phone]•Fax[phone]
www.co.durham.nc.us/ceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
briar)rn YG-ire4tvn
N0o W kclru� . 1 . Su ik✓ 4A1D
Strut. ddress'^ h 1 r glivn
Cit e �2 1 ou State 1a?V`e 'l mite"' ri . ari' 1
Telephone -ax Email •1
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.
f3�an
Date Type o Print Nam
11. .'1?A. (9( V 1 Dtra i✓ LerV8__D py. id9V►4 4.v
Te ph one Fax T' Authorit
lexa
SACntAA
Email ((JJ S ature
**************** ******************************************************.**************.k***Rik**********************.eK*****************
Business Applicant(Provide corporate resolution on siu.natorv-authority)
I, C` —V— ,a Notary Public of the County of CALK.—
State of f tll/c,. CeLvo / ,hereby certify that l,"7✓1 t*tn
personally came before me this day and acknowledged that he is V) Te C y 0 ON (Or
r.f i S and acknowledged,on behalf of r(/\1,Gv) W)..A" 3 c(py d O ILL
`�. •E % ,the due execution of the foregoing instrument.
,o`er
o mWitn s il}Y'iand and official seal,this ( day of ' Vl " ,20 '13
Q' �a� Z � � � L
- o Vic°fic(V
Cl_J�� �
a°p Q Notary blic
e\`•NMy c i i Asion expires D((kyln)pov. ,20 Z3 •
t4lfitw+
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.
Ina" AeitLW
D to Type c r Print e
lq. l`Lt-1 _bt0 1}A Dlr pe c a d_ D.a acte kax
Tele hone ,F,,a, "
Fax Titl o Au ontY
_IlL ItC !��,�i I`,�Il/ h.(124' 1
Email Signa u
***********************************************************************************************************************************
Business Landowner(Provide corporate resolution on sienatory authority)
I, )0,CA ‘te, `t. t\(•___ ,a Notary Public of the County of q_;L -
State of [NI/y36. t CO.,,A;• — ,hereby certify that l C." ,C'..s CAA.4. VV.-N..
1
personally came before me this day and acknowledged that he is ��/•-CC r - ec k c, ;mod .,-c-1 eypp y\c
of t\-701..1p Y.�-\pyy-IS-S�C and acknowledged,on behalf of S -/y�\D.-1 (Ya ✓\ .—.fit S t L C
\o.�"��ttt 1IIIIi!<<4//r "_ ,the due execution of the foregoing instrument.
+�`- Qavrtness my find and official seal,this 1 day of Sk ,20`ZJ�
v
G°Jfi�ry�. —1= Notary P is (1��L
� bmnin expires (� Ems ✓ ,20'23
' ltt��\ii/lllimitt
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