NCC242526_FRO Submitted_20240820

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
I3E0 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:Colonial Village Family Fare Extension: Yes or 0
2. Road location of land-disturbing activity:2110 N Roxboro St
Tax Map-Block-Parcel: 108767, 108768 PIN:0832-25-64-9836,0832-25-65-2641
3. Square footage of land to be disturbed or uncovered:47,396 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):
MM Fowler Inc.
Name
4220 Neal Road
Address
Durham NC 27705
City State Zip
919-309-2925 Ext.8215
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.
MM Fowler Inc.
Name
4220 Neal Road
Street Address
Durham NC 27705
City State Zip
919-309-2925 Ext. 8215
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.du rham.nc.us/ceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Lee Barnes
Name
4220 Neal Road
Street Address
Durham NC 27705
City State Zip
919-309-2925 Ext.8215
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.
02/23/2023 Lee Barnes
Date Type or Print Name
919-309-2925 President
Telephone Fax Title or Author'
[e-mail]
Email Signature (/
Business Applicant(Provide corporate resolution on signatory authority)1, (A) (I AM 3 W ��Es ,a Notary Public of the County of D d Q a A
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State of NGarra CA fD1..4 ,hereby certify that /)'l .L. 401.145 (TA wJ(2
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personally came before me this day and acknowledged that he is PROS de.•i• . = ` :�Ot A R y•'•.'9
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of Ai hi Fe !/ G and acknowledged,on behalf of ^+ �. F•'-4.i 1 a rj
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,the due execution of the foregoing instrument. .................. .....
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Witness my hand and official seal,this �-y 41
day of r G 6Rv Ai= 20 14‘/ `l�L/ C O
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Notary Public �S l
My commission expires_ OCTGgtp 'S ,20 L7 .
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.
2/27/23 Lee Barnes
Date Type or Print Name
919-309-2925 President
Telephone Fax Title 9 Authgri
Ibarnes@fa milyfarecstores.com Z 'Z 7-Z3
Email Signatu e
Business Landowner(Provide corporate resolution on signatory authority) \‘‘‘" I II /101/1��/
I, Cu) ;I(.��w. a. w.'G' t _ ,a Notary Public of the County of P 2 il Qt., ��� �P .••' '•••. '�<c`
State of NORTH f CMO l %w n - hereby certify that � ► 8 Rf��S %�. _ .• p A R y�'•;�
personally came before me this day and acknowledged that he is P cs dao
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of _ hi m F pu/Cf,,T-r-c and acknowledged,on behalf of M. /h. fob`ck1'.-G % ' `
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,the due execution of the foregoing instrument. ///////I CID``\���0�
Witness my hand and official seal,this 2 7 day of FeirA•AA1 ,20 23
Cam- i^C
Notary Public
My commission expires OCTo 404 (i". ,20 2-7
.********..****************************************.*********.******.****...***************.************************************.
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