NCC215308_FRO Submitted_20210927

JCN
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: The Home Depot — Durham,NC - Parking Lot
2. Road location of land -disturbing activity: 3701 MT MOMAH RD DURHAM, NC 27707 35.949839° 78.994239°
Tax Map - BIock - Parcel: xxx - xxx - 141418 PIN: 0800-03-10-9599
3. Square footage of land to be disturbed or uncovered: 73,955
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
HD Development of Marvland INC
Name
ATTN Property Tax Dept 3620
Address
Atlanta GA 30339-5842
City State Zip
[phone] david_kazeroonighomedepot.com
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.
HD Development of Marvland Inc. - David Kazerooni
Name
2455 Paces Ferry Rd SE
Street Address
Atlanta Georgia
30339
City State
Zip
[phone]
david_kazeroonig_homedepot_com
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.
201 E. Main St, Sty' Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durham.nc.us1ceng

■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
City
G. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
HD Development of Maryland Inc., Johnathan Pritchett, Store Mgr
Name
3701 Mt. Moriah Road
-St r eet Address
Durham _ NC 27707
State
_(919) 419-0208
Telephone
Fax
zip—
Johnathan [e-mail]
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.
07/29/2021 David Kazerooni
Date Type or Print Name,"
770)384-2280 Senior
Telephone Fax Titl
_david kazeroonighomedepot.com
Ei
mail ianak
Business Applicant (Provide corporate resolution on signatory authority)
I, , a Notary Public of the County of
State of hereby certify that David Kazerooni
personally came before me this day and acknowledged that he is Senior Manager — Civil / Stormwater
of HD Development of Maryland Inc. and acknowledged, on behalf of HD Development of Maryland Inc.
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of .20
Notary Public
My commission expires 20
Individual Applicant
1, 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.
S. 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.
07/29/2021 David Kazerooni
Date Type or Print Name
[phone] Senior ManagkfA CbA4 / Stormwater
Telephone Fax Title or
david [e-mail]
Email Sitr A
Business Landowner (Provide corporate resolution on sianatory authori
C uGIAGj�, a Notary Public of the County of '—
State of C.%.QDQ, hereby certify that David Kazerooni
personally came before me this day and acknowledged that he is Senior Manager — Civil / Stormwater
of HD Development of Maryland Inc. and acknowledged, on behalf of HD Development of M land Inc.
1,, the due execution of the foregoing instrument.
1�,TE0 I gnt t f� l.Y� l day of 20
Notary Public, Georgia
•?`.: Dekalb County 6.
? �2`�P�a My Commission Ex fires Notary Public
20 .
Individual Landowner
I, , a Notary Public of the County of
State
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
5E-03 Rev.07/06