NCC241466_FRO Submitted_20240514

MCCORMACK
.BARON
SALAZAR
May 31, 2023
Mr. Dylan Reinhardt
Regional Engineering Associate
Division of Energy, Mineral, and Land Resources
Department of Environmental Quality
3800 Barrett Drive
Raleigh, NO 27609
RE: Southside Phase III/ly Erosion and Sedimentation Control Permit Application
Dear Mr. Reinhardt,
Please find enclosed a revised Financial Responsibility Form and a Letter of Consent for the Southside
Phase III/IV erosion and sedimentation control permit application previously submitted. Please let me
know if you need anything further.
Thank you,
447/71
Judith Jones Moran
Senior Vice President/Project Manager
XC: Mark Taylor, P.E., Land Design
McCormack Baron Salazar,Inc.
St.Louis Office 100 N.Broadway,Suite 100 St.Louis,Missouri 63102 Phone[phone] www.mccormackbaron.com

Addendum to FR/O form Part A, Item 9: Landowner of Record Letter of Consent
City of Durham
Landowner of Record Name:
Property Tax ID#/PIN:
Property Address Line 1: 217 Memphis Street PIN#0821-93-45-4194
Property Address Line 2: 230 St. Joseph Street PIN#0821-93-03-5259
City/State/Zip Code: Durham, NC 27701
Applicant submitting plan -must match the financially responsible party named in Part B
Section 1 of the Financial Responsibility/Ownership(FR/O) Form: McCormack
Baron Salazar Development, Inc.
Statement of Landowner Consent: In accordance with NCGS 113A-54.1(a), I hereby declare
that I am the owner or legally authorized representative of the owner of the property described
above and provide my consent for the applicant cited above and in Part B of the FR/0 form to
submit a draft erosion control plan to the State of North Carolina and to conduct the planned
land-disturbing activities on the property listed above and in Part A of the FR/O form.
Wanda S. Page City Manager
Type or Print Name Title or Authority
(i /4. °111-'t5 - / q �,V
g
Si naK,re Date
[e-mail] 919.560.4222
Email Telephone

heck if this project is ARPA-funded ❑
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameSouthside East Phase III/IV
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Durham `City or Township Durham
Highway/Street Memphis Street Latltude(dedmal degrees)35'98 Longitude(dedmaI degrees)-78'90
3. Approximate date land-disturbing activity will commence:August 2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.):Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):5.50
6. Amount of fee enclosed: $600 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mark Taylor E-mail Address [e-mail]
Phone: Office# [phone] Mobile#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
City of Durham 919-560-4750 X2226 919-730-5995
Name Phone: Office# Mobile#
101 City Hall Plaza
Current Mailing Address Current Street Address
Durham NC 27701
City State Zip City State Zip
10. Deed Book No.5821 Page No.240 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
McCormack Baron Salazar Development, Inc. [e-mail]
Company Name E-mail Address
100 N. Broadway Suite 100
Current Mailing Address Current Street Address
St. Louis MO 63102
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Richard Valzonis [e-mail]
Name of Registered Agent E-mail Address
807 E. Main St. - Bldg 2, Suite 200
Current Mailing Address Current Street Address
Durham NC 27701
City State Zip City State Zip
Phone: Office# [phone] ext. 22226 Mobile# [phone]
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name,attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Michael Saunders Vice President
Type or print name Title or Authority
kite/11 , ~ 4-- f I D)Z0Z 2)
Signature Date
CY'F-j
I, 1 1 AncjjreA-_ Janet' , a Notary Public of they of_ . `.O-'k S
AA is5c C-1
State of rdtiftvagmole, hereby certify that i yvichrLei c5 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of ;n a_ , 20 2 3
1 )`A, �X)
D'ANDREA JONES Notary
Notary Public Notary Seal
State of PrAouri
St. Louis City My commission expires 1 ) 4t 7L 7
Commission # 21832123 I 1
My Commission Expires 01-04-2025