NCC215550_FRO Submitted_20211006

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
2. Road location of land -disturbing activity:
N A-,
07
Tax Map -Block -Parcel:. Mr PIN:
165015 1 -b 1657oaLi
3. Square footage of land to be disturbed or uncovered:
4. List below the landowner of record. Each landowner must complete Item S.
(If there are mAple pwners,'please list on a separate page):
--
Name
gyH4
dre s G z77o3
to f
Ci
State Z ou a 0 oaf' o+K� 4 kdtfA(k;1.e.0r^
Off �- 6y 6 - 06e
Telephone Fax Eraa'l
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
indirectly allowed the land -disturbing activity or have benefited from it and (3) �party on the Land Disturbing
Permit.
L.C..
Name
Street Address ,n „� 1 . C
�( 1'v Zi
Cit State p
__��Z39 r'ol
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, 511 Floor, Durham, N.C. 27701 • [phone] is Fax [phone]
www.co.durhaw.mus/ceng

JCN
Durham City/County (Omoe Use Only)
Sedimentation and Erosion Control
(� 46 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
%W WITH LANDOWNER CONSENT FORM
No person my initiate any land-distiubing activity covered by the Durham City -County Unified Development Ordinance before a
land Disturbing Permit Is issued by the Sedimentation and Fission Control Office. Issuance of a Land Disturbing Permit does not
relieve the peamittee of the obligation to obtain any other licenses, permits and approvals as may be inquired by Federal, 6tsM
County or Municipal governments. This office most be notified in writing of any change to the infbxmation on this form.
PLEASE TYPE OR PRINT ,.r�
1. Project name: rr'm Q1er /�j✓G+K,�.0 •a —Fa "
J
2. Road location of land-fthwbing activity: (� �l tX' i+taPr
aIc501�,I ig ols165�2%v; 674
-te Taz Map -Block -Parcel: �a7
3. Square footage of land to be disturbed or uncovered:
4. Ll.t bdow the landowner of record. Each landowner mast complete Item ti.
(If there am multiple owned+ Pleagp 49 on q soParate Page):
Li— STIO
7
state
Fax Email
S. IM the parson or entity finanelally responsible for this land-dlaturbitog ae"ty: T'he Snanoially ale ley eJmll
be (1) the developer or otter parson who has or holds themselves as having fnaaolal or operational control over the land -
disturbing aedvity and/or (2) the land owner or person in possession or control of the land whoa they have directly or
indirectly allowed the land -disturbing; activity or have bmefibed Srom it and (5) the named party on the Land Dblurbing
Permit
Name 5.71 r 5-7y J FrKs i*a d, 0
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 cro inn control plans, if require4 on site.
Display prutalt on site.
• Understand and implement any required Plan, inohtding the construction segaence anddaW&
■ Inspeck maintain and repair sedimentation and erosion control measures, especially aibpr 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, 50 Floor, Durham, N.C. 27701 • (9M 560-0735 • Fax [phone]
wwwxnAufinmmorrramg

■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
6. For bushiness applicants, list bellow the North Carolina registered agent for the financially responsible entity:
Name S7 It -S/
Street Addrle�ss _ ���� ✓V� 2i�y�
City `V "I 2.2l �2,3 b to 1p �►AF;r� 9J '�`�Ooe��.0 vM
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 IAnd 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.
#k#rtk###kk#########rtk#rt##kkkkk###rt#rt##rtk#####k#kkk#k##rt*##rt#rtrt##rtk#kk####rt##rt####+kk########tk#*k#####kk#rtrt#k###4###rt#rtrtrtk#rtrt###rt#k#
Business.AimlicautdProvide coroorate resolution on signatory thori
I, a Notary Public of the County of
State of hereby certify that
personall came before me this daily and acknowledged that he is G
ofA. and acknowledged, on behalf of
, the due execution of the foregoin instrument.
Witness my hand and official seal, this day o M&A720 I
MARY HILL HEROLD
NOTARY PUBLIC Notary Pub
WAKE NDQW0M-i*(N.Qpires , 20JV�.
My Commission Expires 9-24-2021.
# #4 rt ##### k44rtk#kk#k##krt#k######krt#rt#krt##kk####kk##rt#rtk#k#rtk#rt##k#k##rtrtkrtkk##N#####k#k4####rt#k##k#kk########
Individual Annlicant
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
LAND DISTURBING PERMITS ARE, NON -TRANSFERABLE

S.
Provide a Notarized Item 8 for each landowner listed In Item 4.
Land Owner Consent. As n landowner, I provide my consent for land -disturbing activities to occur on the property listed in
He�2 by th person or entity listed in Item 5.
-f,
�'.
-'e Z' /'�
Bgimess Landowner(Provide corporate lutiott on knatory authoriW
a Notary Public of the County of
State of Aj `� i f(•� Z-G=t l i aLAI, ✓ �,/la t i— :....SP ex--c
pemonRUY came before me this day and acknowledged that he is
of01 and acknowledged, on behalf of
1 ► �-. {� _ ._.._. the due cxmwion of the forgoing instriuuent• it E p
Witness m hand and official seal this oil
(�9�'1'
y �
Notary Public \
My commission expires e A. K 20 a '• (/B L1G ' U
1 U) .... ��e�♦
#srt►#######4K9K+F#+Y#a#K#*#KKKqK##Yi###A+#K#iA#AK##*##s##K##K#aK#K##trt!###KKt##K###Y###ik##►KKK#1#r#Kf*M#sy#k#KMK1###K#K ,,��.�' 6
]ndi diluO,Landowner
State of
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
20
S&03
Rev.07/06

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, w
Date Type or Print Name
R 17- 4f `7--�- - !1� /
Business Landowner (Provide corporate resolution on sig>natory authority)
State of
a Notary Public of the County of
hereby certify that
personally came before me this day and acknowledged that be is
of
Witness my hand and official seal, this
My commission expires
and acknowledged, on behalf of
the due execution of the foregoing instrument.
day of
Notary Public
20
20
##rt###rtt#ttk#rt##t###k#rtt###trtrt#M#t##tt###rt#tt#rt#rt##############rtt#rtrtrt#########kt#rtt##4t##t#rt##t###t####t#trt###t####t#rt#rt#####t##s
Individual Landowner
I, S a Notary Public of the County of UU&a4l&
State of ' 4k(,Pao LVLA- , 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 AT20 21
kuugvj-14�
NotaryPublic
My commission expires E-14 L , 20 X.6
S&03
Rev.07/06