NCC216785_FRO Submitted_20211208

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: Abby Ville/Wood
2. Road location of land -disturbing activity:5444 Fayetteville Road Durham NC 27713
Tax Map - Block - Parcel: 206521 PIN:_0729-03-21-0750
3. Square footage of land to be disturbers or uncovered:-0.75 acres
4. List below the landowner of record. Each landowner must complete item &
(If there are multiple owners, please list on a separate page):
Nvme —IAT I/01) I'
mY ��he� r� u�1 va,� d���G��•,
Address 3 gO b C mT co t t 2T
City p(Ak [ *� State N C Zap 3
Telephone �T Fax Email 3' Ua -I r, 0-ax y
lelq -931 2S-?a 5. List 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
Name n f)` 11 i/0 b &A 12 Ll rl L ( C
Street Address
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city D State AJC zip 2
Telephone l I z � Fax �%� Email r^a �1 V a r,r.C.�_ CP 9M� �r
The Sedimentation and Pollution Control Act (Act) and the Durham City -County Unified Development Oradinance
(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.
a Inspect, maintain and repair sedimentation and erosion control measures, especially after rainfall events.
f Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
201 E. Main St, 5'11 Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durbam.oc.usiceng

• 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:
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Narne ',J� < R A If ,9 / V LJ5&
Street Address
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City QWQ Hq (I State n I � Zip 2
Telephone l 4.3 I _ Z� Fax IVIk Email Yu&' sS U (2 � �, .e tC •ems, l fsr�zi l CO S
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The above information is true and correct to the best of my knowledge an 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.
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Business Applicant {Provide corporate resolution on signatory authority)
1, f A)K- crl`� , a Notary Public of the County of 1 r1 r
State of 1j i) V , hereby certify that n r
personally
came before me this day and acknowledged that he is �� Q
of !/1"t Q V Of]Y UC lA Ni Z -L-4L_ and acknowledged, on behalf of :jn-g?t1 U l' Gl m. '�=�
, the due execution of the foregoing instrument.
Witness my hand and official seal, this 4&)41 da�=gp
of n Gi 20
ulip
My commission expires` C2�'o 20 �
ANATU AKINSETE
Durham Co., North Carolina
Individual Applicant My Commission Expires Sept. 30, 2023
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 there.
Witness my hand and official seal, this day of 120
My commission expires
20
Notary Publir
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE

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_
Date int Name
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Telephone Fax Title or Authority
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Business Landowner (Provide corporate resolution on signatory authori
I, A at4 l n5 �.�� , s Notary Public of the County of L�LA+ -V\-(A yY
State of N1 n ar Di I nc , hereby certify thatf7V'Gi r 5 Va!o
personally came before me this day and acknowledged that fie is �� 0
of 6 #T6 Vo Pk k u H L L C and acknowledged, on behalf of ag-fa uodar[,1m
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of20 3_d
r� N
My commission expires .s j p`� c20
Individual Landowner
I, , a Notary Public of the County of
State
hereby certify that
ANAT((]]l1 yA/ KPP INIISETE
Durham Co,, North Carolina
My Commission Expires Sept. 30, 2023
personally appeared before me this date and under oath acknowledged that the above form was executed by thetas.
Witness my hand and official seal, this day of 120
My commission expires
20
Notary Public
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