NCC241258_FRO Submitted_20240426

JCN
DURHAM
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
jirIP WITH LANDOWNER CONSENT FORM
�tset
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: Novo Nordisk OFP Tropical Storm Extension: Yes or No
2. Road location of land-disturbing activity: 5235 International Dr
Tax Map- Block- Parcel: Block 1045 Tract 002100 PIN: 0845468342
3. Square footage of land to be disturbed or uncovered: 698,665 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):
Novo Nordisk Pharmaceutical Industries, LP
Name
3612 Powhatan Rd
Address
Clayton NC 27527
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.
Novo Nordisk Pharmaceutical Industries, LP
Name
3612 Powhatan Rd
Street Address
Clayton NC 27527
City 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,5' Floor, Durham,N.C.27701•[phone]• Fax[phone]
www.co.durham.nc.us/ceng

6. For sines app ' nts,list below the North Carolina registered agent for the financially responsible entity:
• G “,(G2'n514:
Nai 52.35 �r�1- rna ,o(I ( Or
Street A • (Ina rY) NC
77 I ^
-(
aC
Cib, State
iq)atdce--015 q 1114 ejtxPe.t.L 00v0 florkS k...CoM
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. l
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.
..ci*I-2023 1c Pc,(1c2Y nsK-:
Date Type or P 'nt Name
(9(�) �6 - /6? NtA Vice. �res:Acn-f
Teleph ie n l I 1 Ti A ,
Pn lv�4runOr(/tt 5., cork % _
Email S ature
Business Applicant(Provide corporate resolution on signatory authority)
1, `3 (1O ,t.)%3 M r--a Notary Public of the County of \r�/Y1C_Q
State of1+4 eDUIOLlff1t./ ,hereby certify that e 1 udc:31f15Lr✓
personally ca before me this day and acknowledged that he is
of 1 yOJ6 CLtiSIC,- Si4C.. Wed acknowledged,on behalf of !VOW) (Va -C1(,
phoorrmt C ,_ ccx) 9 • ,the due execution of the foregoing instrument.
Witness my hand and official seal,this cPc3 day o A Spier‘en [s
123 ,20 a4 1 Gt 1 c)`S VOrt I-2.i'L
N.ota ,� blic INA DAVIS LIMER
My commission expires oop 30 20 a5 NOTARY PUBLIC
VANCF CQ,I�NTy Ncr......,< ..
y commbslon E vest 025
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.
Date Type or Print Name
Telephone Fax Title or Authority
Email Signature
Business Landowner(Provide corporate resolution on signatory authority)
I ,a Notary Public of the County of
State of ,hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged,on behalf of
,the due execution of the foregoing instrument.
Witness my hand and official seal,this day of •20
Notary Public
My commission expires ,20
*******************.********.**************.**.****.*******.**********.***********************.**********.***********************
Individual Landowner
,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

i