NCC215626_FRO Submitted_20211011

DURHAM
COUNTY
10Q
• 1881
Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
FINANCIAL RESPONSISILITYIOWNERSHIP 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
t. Project name: Pelican Property
2. Road location of land -disturbing activity: Doc Nichols Road
Tax Map - Block - Parcel: PIN• 0850-03-92-6767 0850-03-91-0703
3. Square footage of land to be disturbed or uncovered: 52.54 ac / 2,288,642.40
4. List below the landowner of record. Each landowner must complete Item S.
(If there are multiple owners, please list on a separate page):
Capital Properties of Raleigh IV, LLC
Name
3724 National Drive, Suite 220
Address
Raleigh NC 27612
City State Zip
910-233-8581 [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.
Capital Properties of Raleigh IV, LLC
Name
3724 National Drive, Suite 220
Street Address
Raleigh NC 27612
City State Zip
910-233-8581 [e-mail]
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, 5" Floor, Durham, N.C. 27701 a [phone] • Fax [phone]
www,co.durham.nc.uslceng

■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
David Stallings
Name
3724 National Drive, Suite 220
Street Address
Raleigh NC 27612
City State Zip
919-618-2060 david@a7_shenandoahhomes.us
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.
03/22/21 David Stallings
Date Type or Print Name
919-618-2060 Manager
Telephone Fax Title or Autho
david@shena ndoahhomes. us
Email Signature
Business Applicant (Provide corporate resolution on signatory authority)
1 Konstantina Bakatsias , a Notary Public of the County of Wake County
State of North carolina , hereby certify that David Stallings
personally came before me this day and acknowledged that he is Manager
of Capital Properties of Raleigh IV, LLC and acknowledged, on behalf of Capital Properties of Raleigh IV, LLC
the due execution of the foregoing instrument.
Witness my hand and official seal, this 22nd day of March 12021
Notary Public .�`�'`�-�1NA $„�'`'�•,
My commission expires c ! e bcr / , 20 �
Individual Applicant _Cfj
- NOTARY
PUBLIC
I, , a Notary Public of the County of SS
r- 15
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
20
day of 120
Notary Public
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE

Provide a Notarized Item S 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.
03/22/21 David Stallings
Date Type or Print Name
919-618-2060 Manager
Telephone Fax Title or Auth
[e-mail] -
Email Signature
Business Landowner Provide co orate resolution on signatoKy authori
1, Konstantina Bakatsias , a Notary Public of the County of Wake
State of North Carolina
hereby certify that David Stallings
personally came before me this day and acknowledged that he is Manager
of Capital Properties of Raleigh IV, W'acknowledged, on behalf of Capital Properties of Raleigh IV, LLC
the due execution of the foregoing instrument.
Witness my hand and official seal, this 22nd
day of March
2021
f�
Notary Public ~—�'
My commission expires ,�, �S, 20 `
boll', F+
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Individual Landowner = p N', (P
"
a Notary Public of the County of = NOTARYPUBLIG
State of ,hereby certify that
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personally appeared before me this date and under oath acknowledged that the above foem.
rnt'�y��°ii�eb�'th
Witness my hand and official seal,
My commission expires
20
day of
Notary Public
20
5E-03 Rev.07/06