NCC216427_FRO Submitted_20211207

DocuSign Envelope ID: E097225A-6181-40D9-B1 EB-623885E36362
Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
[, 0 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
M 10) 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: McDonald's
2. Road location of land -disturbing activity: 4301 N. Roxboro Street
Tax Map - Block - Parcel: 127516
3. Square footage of land to be disturbed or uncovered: 49,968
PIN: 0823-08-87-3687
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
McDonalds Real Estate Company
Name
10532 Byrum Woods Drive
Address
Raleigh NC 27613
City State Zip
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.
McDonalds Real Estate Company
Name
10532 Byrum Woods Drive
Street Address
Raleigh NC 27613
City State Zip
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, 5tn Floor, Durham, N.C. 27701 e [phone] e Fax [phone]
www.co.durham.nc.us/ceng

DocuSign Envelope ID: E097225A-6181-40D9-B1 EB-623885E36362
■ 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:
Name
10532 Byrum Woods Drive
Street Address
Raleigh NC 27613
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. 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.
Date Type or Print Name
Telephone Fax Title or Authority
Email Signature
Business Applicant (Provide corporate resolution on signatory authority)
I, , a Notary Public of the County of
State of , hereby certify that
personally came before me this day and acknowledged that he is
of
and acknowledged, on behalf of
, the due execution of the foregoing instrument.
Witness my hand and official seal, this day of 20
Notary Public
My commission expires 120
Individual Applicant
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 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

DocuSign Envelope ID: E097225A-6181-40D9-B1 EB-623885E36362
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.
8/4/2021 Tony Valevicius
Date Type or Print Name
630.209.7371 Senior Counsel t—DocuSigned by:
Telephone Fax Title or Authority I I-6V,4 Uk,,,AiUItiS
Signature
Business Landowner (Provide comorate resolution on si ng atory authority)
I, Victoria Vockeroth , a Notary Public of the County of cook
State of Illinois , hereby certify that Tony Valevicius
personally came before me this day and acknowledged that he is Senior Counsel
of McDonald's Real Estate Company and acknowledged, on behalf of
l
the due execution of the foregoing instrument.
Witness my hand and official seal, this 4th
My commission expires January 16 , 2024
Individual Landowner
I,
day of August 120 21
Notary Public
OFFICIAL SEAL
FNAA�
ORW OLL
A oRO ols
ommission Fires 1-1&24
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
My commission expires
20
Notary Public
SE-03 Rev.07/06