NCC233456_FRO Submitted_20231128

DURHAM JCN 6792-/2
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
0' FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
nc: 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 p
1. Project name: i� land P/R L 0745 32--55 Extension: Yes or 0
activity: r // from/La/(es Dr Ow�l,4r,Ivc
2. Road location of land-disturbinga yG Zvi a Rd. + 5�'ru , ,477/3
Tax Map-Block-Parcel: 2 el8 9174-3 PIN: O 72 9- oZ -7 8 - 2558
3. Square footage of land to be disturbed or uncovered: /l, 82-/Q .SF
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate age):
EGL.C7414v000l Ho..w e S o f Ra/e l it/ 1.1.
Name
7/0/ Crcee/i•,00i Rai. -Sui -e //5
Address
Ra/cy'A Nc 276/3
City State Zip
T/T-758-8208 Acrawfoidc? eas14wood.4e,•res. Co.vr
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 otherperson who has or holds themselves as having financia for 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.
Eas7wood No.•les 074 /Qa/e,,`, ,
Name /�
7/O/ Ceecd oor Rd .su/.74C //5
Street Address
2 7�/s
4/e� G
City State Zi
758-8208 Glc easfw000/Lio.•+es, co.•,
Telephone Fax Email
AC As the Financially Responsible Party,I consent to receiving notifications regarding this project via electronic
(initials) communication at G{crawToro/€P eas7 woDealt; ,Ne$. cOfrol
(Email Address)
I agree to provide any updated email addresses as necessary to ensure consistent communication is maintained between myself
and Durham County Sedimentation and Erosion Control.
Electronic notifications may include Plans Review Comments,Approvals,Disapprova ls,and/or enforcement actions including
Notices of Violation, Stop-Work Orders, and/or Civil Penalties.
201 E.Main St,5th Floor,Durham, N.C. 27701 • [phone]•Fax[phone]
www.co.durham.ne.uskeng

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 underoath. 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.
14/'3/ A I Craw Ao✓u'
Date Type or Print Name
919- '27-29‘2. Vices Picsicl�tif
Telephone Fax Title o Aut ority
acraw7 e o"a� easfwcodA,A*,es.cor, l--�
Email gign re
***********************************************************************************************************************************
Business Applicant(Provide corporate resolution on signatory authority)
1, 2ar�Ack. F-o lSOdv\ ,a Notary Public of the County of WO-VC_
State of 1110 ( eac) 1CA- ,hereby certify that 4 e.4 / A acoP> d
personally came before me this day and acknowledged that he is VtCP -4eSAe -4-
of 0,QY1S-6tAlAl Jv\ and acknowledged,on behalf of 't_li.- - MeS cC (2 cd L,LC,
nnn, „�
,the due execution of the for-..ing instru ii -nt. ,`s`‘.%'� l „
Witness my hand and official seal,this 3( day of . • ' ,2 'ty Cori;• • O •,
r"
•Notaryb,c �',�, Ay d: O
My commission expires c9 ,20@,C0 . ;w </
? ,3 C ,
° /j/
lll
Individual Applicant ,,,,, ,, ��`,,,,
,�N'',
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
Provide a Notarized Item 8 for each landowner listed in Item 4.