NCC217061_FRO Submitted_20211220

Financial Responsibility Ownership r ENGINEERING
(Sedimentation Pollution ControlAct) SERVICES
One Excha ge Plaza, Suite 304
Raleigh, N 27601
This section to be completed by City of Raleigh staff
Submittal Date Effective Date
Transaction Number Permit Number LD-
The remaining sections to be completed by the Applicant
SECTION 1: GENERAL I FORMATION & INSTRUCTIONS
This form is required to be completed, notarized and submitted with all Land Disturbing Permit applications. The
information provided herein becomes an enforceable part of the approved Erosion and Sedir ent Control Plan
and the Land Disturbing Permit listed above. Non-compliance may result in the assessmen of civil penalties
and could potentially affect all permits, inspections and/or Certificates of Occupancy for this Project. Should any
of the information on this form change, a revised, ex cuted form shall be submitted within thi�ty (30) days, said
submission shall include a copy of any documents rec rded with the Register of Deeds.
The effective date of this form shall be the effective date as designated above by the City of Raleigh. No rights
and liabilities associated with any designation shall in ur until the effective date, or the effective date of transfer
to any subsequent Party. Upon any delegation of an Applicant/Permittee or Financially Responsible Party, the
Owner shall continue to receive notice at the address brovided.
A permit may not be transferred to a residential F
Financially Responsible Party, until the issued Land
by the Stormwater Management Division.
Raleigh City Code §14-1011 sets forth that it shall be
false information or misrepresentations in any applica
disclosure of the requested information may be groun
Please complete all sections below. Type or print an
the blank. All pages of this form must be completed
The property owner must initial each page of the form
Owner's Association as the Applicant/Permittee or
rbing Permit for this project is administratively closed
Inlawful and a violation of this code for any person to give
on or permit required by this code. Failure to provide full
s for denial or revocation of a Land Disturbing Permit.
, if information on the form is not applicable, place N/A in
and submitted or the form will be rejected and returned.
)rior to submittal.
SECTION 2:
PROJECT INFORMATION
PROJECT NAME Chapel Ridge
PERMITTED PHASE(S) Lot 490
PROJECT ADDRESS 102 Bur Oak
ourt, Pittsboro, NC 27312
WAKE COUNTY
NUMBER(S) PARCEL ID 9734-00-12-4904
i
DATE
PROJEICT PATED INIITIIAT ONOF 1 2/1 5/2021
EXPECTED DURATION OF PROJECT 10 months
ACREAGE OF LAND TO BE r
DISTURBED 1�'�'� 0.41 ac
i
PROPERTY OWNER'S INITIALS: WL
Stormwate Inspections Form 112
08.01.16
Page I of 5

SECTION 3: PROPERTY OWNER INFORMATION I
Elm Street Builders, LLC
PROPERTY OWNER OF RECORD
3434 Kildaire Farm Road, Suite 240 919.810.9163
MAILING ADDRESS (NO P.O. BOX)
Cary, NC 27518
CITY, STATE, ZIP
The undersigned acknowledges that he is the
which is the subject of this application, and
authorized to be conducted on the subject p
Owner.
TELEPHONE NUMBER FAX NUMBER
[e-mail]
E-MAIL ADDRESS
or holds the Owner's power of attorney, of the property
states that the permitted land-disturOng activities are
with the full knowledge, permission and consent of the
The undersigned acknowledges that he is the Property Owner for permit implementation compliance and
enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance, Article 9.4. The
Owner of the property upon which the land -disturbing activity is to be undertaken states and affirms that he has
read and understands the statements and disclosures made in this form and that the information disclosed
herein is true and correct to the best of his knowledge and belief.
This form must be signed by the Owner of the prope ty or by a person with authority to execute instruments, if
the Owner is not an individual.
This, the day of ffoyi
PROPERTY OWNER SIGNATURE
IN WITNESS WHEREOF, the undersigned
day of lLlovengbcr
r^uyla k.. Fie rV&A
Notary FAbblic (print name)
My Commission Expires:/l•(l,��,
PROPERTY OWNER'S INITIALS: Calcl
20.
%L
TITLE
ry Public has hereunto set his hand and seal, this
Notary ublic Signature
Notary Publ
/ Position
BRYNA, R. F' EEMAN
NOTARY PtJBLIC
Wake Cry my
(SEAL) North Car Tina
My Cornmissbn Ex„ i s Feb. 18, 2023
Inspections Form 112
08.23.16
Page 2 0
f 5

SECTION 4: OWNER'S A POINTED AGENT INFORMATION
The Owner of the property upon which land -disturbing activities will be undertaken is required to either reside in
or appoint an agent for service with business and r sidence addresses within Wake Count , North Carolina.
Section 4 must be completed if the Property Own r listed in Section 3 does not reside in Wake County,
North Carolina and is optional for all others.
The Owner of the subject property hereby appoints tie following person as an agent to rece ve service of any
notice, process, or pleading in any action or legal proceeding arising out of any matter relating to Unified
Development Ordinance, Article 9.4. The Owner agr es that any notice, process, or pleading ay be served by
and through the undersigned appointed agent and uch service shall have the same force and effect as if
service was accomplished upon the Owner.
NAME
COMPANY, IF APPLICABLE
V 1 1\LL 1 �IYV r.lJ. 0ll/"1
CITY, STATE, ZIP
The undersigned acknowledges that he/she is the
This, the day of
APPOINTED AGENT SIGNATURE
IN WITNESS WHEREOF, the undersigned N
day of
Notary Public (print name)
My Commission Expires:
TITLE
TELEPHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
s appointed agent.
20
TITLE
I
Public has hereunto set his/her hand and seal, this
Notary Public Signature
Notary Public Title
(SEAL)
PROPERTY OWNER'S INITIALS: Stormwate� Inspections Form 112
08.23.16
Page 3 of 5

SECTION 5: FINANCIALLY OESPONSIBLE PARTY INFORMATION,
The Owner of the subject property authorizes the fol owing person or firm as the Financially Responsible Party
for this Land Disturbing Permit. The Financial Responsible Party shall receive service of ar}y notice, process,
civil assessment or pleading in any action or legal Droceeding arising out of any matter rellating to the Land
Disturbing Permit issued under this permit application and Unified Development Ordinance, Arjticle 9.4.
Christopher Weir
President
FINANCIALLY RESPONSIBLE PARTY TITLE
Elm Street General Contractors, In 9198109163
COMPANY, IF APPLICABLE TELEPHONE NU
3434 Kildaire Farm Rd, Suite 240
STREET ADDRESS (NO P.O. BOX)
Cary, NC 27518
CITY, STATE, ZIP
FAX NUMBER
chris.weir a@el
E-MAIL ADDRESS
R
istreetb drs.com
The undersigned acknowledges that he is the Fi ancially Responsible Party for permit implementation,
compliance and enforcement resulting under this Lad Disturbing Permit and Unified Development Ordinance,
Article 9.4. He has read and understands the statements and disclosures made in this form, that the information
disclosed herein is true and correct to the best of his knowledge and belief.
This form must be signed by the person or firm financially responsible for the land developing activity or other
person with authority to execute instruments for the fir ancially responsible party, if not an individual.
This, the day of
FINANCIALLY RESPONSIBLE PARTY SIGNATURE
IN WITNESS WHEREOF, the undersigned I
-� day of / 10 ,
Notar ublic (print name)
My Commission Expires: A .11A
PROPERTY OWNER'S INITIALS: 6 "t+
20.
TITLE
,tart' Public has hereunto set his hand and seal, this
NotaVPublic Signature
yolk
Notary PubliVitle / Position
BRYNA R. F EEMAN
NOTARY PUBLIC
Wake County
North lira
(SEAL) My Commission Expi s Feb. 18, 2023
P Inspections Form 112
08.23.16
Page 4 of 5

SECTION 6: APPLICANT I PERMITTEE
The Owner of the subject property authorizes the following person or firm as the Applicant/Permittee to receive
service of any notice, process, civil assessment or pleading in any action or legal proceeding arising out of any
matter relating to the Land Disturbing Permit iss ed under this permit application and Raleigh Unified
Development Ordinance, Article 9.4. The Applicant/Permittee designated below is the person responsible for
implementation of permit conditions and violation under Article 9.4 of the Raleigh Uni ed Development
Ordinance.
The Applicant/Permittee may be the landowner or another party who acknowledges that he is the Contractor
responsible for completion of the project as approved.
Christopher Weir
APPLICANT/PERMITTEE
Elm Street General Contractors, In
COMPANY, IF APPLICABLE
3434 Kildaire Farm Rd, Suite 240
STREET ADDRESS (NO P.O. BOX)
Cary, NC 27518
CITY, STATE, ZIP
President
TITLE
9198109163
TELEPHONE NUMBER
FAX NUMBER I
[e-mail]
E-MAIL ADDRESS
The undersigned acknowledges that he is the Applicant/Permittee for permit implementation compliance and
enforcement resulting under the Land Disturbing Permit listed above and Unified Development Ordinance,
Article 9.4. He has read and understands the statements and disclosures made in this form and that the
information disclosed herein is true and correct to the best of his knowledge and belief.
This form must be signed by the person or firm re,,
execute instruments for the Applicant/Permittee, if not
A
This, the -5 day of 2 reM
APPLICANT/PERMITTEE SIGNATURE
IN WITNESS WHEREOF, the undersigned Nc
5 day of 1VV rem` , 2
Notary Pliblic (print name)
My Commission Expires:
isible for the permit or by a person; with authority to
individual.
20.
TITLE
Public has hereunto set his hand and seal, this
Notary
Notary P
Signature
BRYNA R.
NOTARY
Wake (
(SEAL) North
My Commission Exi
Feb. 18, 2023
PROPERTY OWNER'S INITIALS: Stormwatel Inspections Form 112
08.23.16
Page 5 of 5