NCC190716_ESC FRO Form_20190625

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' Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
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
1. Project name: Lakeshore Town homes
2. Road location of land -disturbing activity: 4224 Lumley Road
0749-04-73-2322; 0749-04-73-1550;
Tax Map - Block - Parcel: 157314, 157315, 157316, 157317 PIN: 0749-04-63-9550, 0749-04-63-7563
3. Square footage of land to be disturbed or uncovered: 295,000 sf (6.8 ac)
4. List below the landowner of record. Each landowner trust complete Item 8.
(If there are multiple owners, please list on a separate page):
Kaaawa LLC
Name
_5804 Tangiewood Dr
Address
Raleigh, NC 27616
City State Zippy
1111 1 �72 —SZ-6S Artgf rf-jB . cirn
Fax
Email
5. List the person or entity financially responsible for this laud -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.
au 4g_ Ho-ne.c. oh ..► 1 LL C c-j , "rt s IZn.KH 111�.�
Name
4;7, j,Z.Zy Crescc.t� �rrI.AQy-:Vc � _ ZS0
Street Address
Z"12" e'' —
City State Zip I
0 l A M b i 1101 C. to r-" t,
Telephone Fax Email IJ
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.
■ Refer to Section I2.10.41:3 of the Durham City/County UDO for groundcover time line requirements.
■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
120 E. Parrish Street, Law Bldg., V Floor, Durham, N.C. 27701 * [phone] • Fax [phone]
www.dcooc.gov/index.aspx?page-]80

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
In i G I� (1l I A
Name
(Z27 C,-esc=�.I' G,.�h �Y;VC
Street Address
City State Zip
IA 431(a tlto I (%,%mot.. 'r 4LL.a4lt4 [1) e NA
Telephone Fax Email 11
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.
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Date �� Type or Print Name
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Telephone Fax Title or Autho;4y
Email 4 t a Signature
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Business Applicant (Provide corporate resolution on signatory authority) , `
I, 7—Eiwwtf C. , a Notary Public of the County of _ + WrA ke I
State of s: �. hereby certify that �Y�ly�k�l�r �Llnk -eti
personallycame before me this day and acknowledged that h�''L e is _ l tn e++ Lit, e t�W� _
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Witness my'fiand and official seal, this �� day of &%nv�► — ?0
N0'rARY z = G l
PUBLIC
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0 My coin r l� on expires �`C !� 2C) �~ , 20 Z .
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Individual Applicant
State of
a Notary Public of the County of
, hereby certify that
personally appeared before me this date and under oath acknowledged that the above fonn was executed by them.
Witness my hand and official seal, this,
My commission expires
20
day of 120
Notary Public
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.
Dat Type or Print Namef
Telephone e` Fax Title or Au t rity
)Etnall Signature
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Business Landowner (Provide corporate resolution on si n� atory authority)
1," G c 1 : r: ( r, , a Notary Public of the County of Wj "1 k-4j
State of �b� +'� V(� v�q , hereby certify that 0 ��
personally came before me this day and acknowledged that he is
Yecenia
09tion6rity, Cd official seal this
MY COMMIsslon Expifes March ii, 2p2p
My commission expires
and acknowledged, on behalf of
the due execution f the foregoing instrument.
! day of Y7 v t , 20 ! I
Nota' Public T
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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
My commission expires
P
day of
Notary public
.20
SE•03 Rov. 10113