NCC217177_FRO Submitted_20220103

Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
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: Kestrel Heights Charter School
2. Road location of land -disturbing activity: 4700 S Alston Avenue lat: 35053'53", long:. 78053'24"
Tax Map - Block - Parcel: 153965,220776 PIN: 0738-03-21-4839;0738-03-11-4419
3. Square footage of land to be disturbed or uncovered: 138,945 sf
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Kestrel Heights Proiect Development. LLC
Name
4700 S Alston Avenue
Address
Durham NC _27713-4419
City State Zip
919.484.1300 919,484 J 355 [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.
Kestrel Heights Project Development, LLC
Name
4700 S. Alston Avenue
Street Address
NC 27713-4419
City State Zip
919.484,1300 919.484.1355 Adri nn Davis(c)Kes� tr„elheghts.org
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, 5th Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durham.nc.us/ceng

■ 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:
Kestrel Heights Project Development , LU
Name
4700 S. Alston Ave
Street Address
_Durham NC _ 27713-4419
City State Zip
919,484,1300 919.484.1355 Adri nneDavis(7Kestrelhemghts.org
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. P¢o'�: �2
kC.S'fiR�1_ L-LC.
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Date glrJ"y8`-1 -13rr Type or Print Name
Telephone Fax Title or Authority _
Email Signature
Business Anplieant Provide c�oz orate resolution on signatory authority)
I, jCt(,rr?P.,n 6Cx7ry ,Y(1 , a Notary Public of the County of
State of . • hereby certify that �t�-�('� tsc�n�
personally came before me this day and acknowledged that he is i�X' a
of 1)[ ►`�Y� and acknowledged, on behalf of
?'Cr fit` l ]C? \l 't�G �f1��- the due execution of the foregoing instrument.
Witness my hand and official seal, this
XG '"N
day of
Notary Public
My commission expires k. c c!C i, 20_�.
Individual Applicant
I,
State of
a Notary Public of the County of
hereby certify that
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puu rm"y
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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
day of
Notary Public
20
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
20

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.
zc Z rDate Type Type or Print Name
Ll i i -,-I Ci'---► - 1' tC_Xj 13r�—
T ephone Fax Title or Author'
a.;;) KCSr) HTS .
Email
Business Landowner Provide cw )orate resolution on siggatory authority
1, QCxr tt n , a NotaryPublic of the County of
State of J '' hereby certify that A42�-<-j QX�hZ �Q I
personally came before me this day and acknowledged that he isj��
of }�, �,� #q;45 S�, u l and acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this CS��"' _dayof , , 2Q.,,,,-�
Notary Public - Q.r:
My commission expires ( 20 %. ; -;-V
s n
Individual Landowner
I> 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.
My commission expires
day of
Notary Public
20
SE-03
Rev.07/06
UC_/