NCC240346_FRO Submitted_20240214

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP 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: TownePlace Suites Extension: No
2. Road location of land-disturbing activity: 3114 Hillsborough Road Durham, NC 27705
Tax Map-Block-Parcel: 119548 PIN:_0821-16-84-6824
3. Square footage of land to be disturbed or uncovered:_1.65 AC 71,874 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):
_Duke Hospitality, LLC_Ketan Patel
Name
_200 Gateway Blvd
Address
Rocky Mount NC 27804
City State Zip
_(252)410-1005 NO [e-mail]
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.
_Duke Hospitality, LLC_Ketan Patel
Name
200 Gateway Blvd
Address
Rocky Mount NC 27804
City State Zip
_(252)410-1005 NO [e-mail]
Telephone Fax Email
As the Financially Responsible Party,I consent to receiving notifications regarding this project via electronic
(Initials) communication at [e-mail]
(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 Is,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.nc.us/ceng

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 under oath. 1
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.
Ketan Patel
Date Type or Print Name
_(252)410-1005 NO Owner
Telephone Fax Title or Authority
[e-mail]
Email Signature
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B sin ss A lic nt r idecoorate resolution on si ato authorit irc)--L.
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personally appeared before me this date and under oath acknowledged that t e above form was executed by the .
Witness my hand and official seal,this Jday of ,20
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Provide a Notarized Item 8 for each landowner listed in Item 4'%9�4 ?4: ;c�.

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.
Ketan Patel
Date Type or Print Name
_(252)410-1005 NO Owner
Telephone Fax Title or Aut
[e-mail]
Email Signature
***********************************************************************************************************************************
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RRRIRR IR II III 111",,
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. I
• 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 ca lendar days.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
SE-03 Rev.07/06