NCC220278_FRO Submitted_20220202

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 perrnittee of the obligation to obtain any other licenses, permits and approvals as may be required by Federal, State,
County or Municipal goven-iments. This office must be notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name: Hebron Village
2. Road location of land -disturbing activity: 4728 Denfield Street
Tax Map -Block- Parcel: 177609
PIN: 0834-03-11-6009
3. Square footage of land to be disturbed or uncovered. 1,073,633 si (24.7 acres)
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Level 5 Ventures, LLC
Name
PO Box 1422
Address
Holly Springs NC
27540
City State
Zip
919-669-5372
[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.
Level 5 Ventures, LLC
Name
PO Box 1422
Street Address
Holly Springs NC
27540
City State
Zip
919-669-5372
keith&15ventures.com
Telephone Fax
Email
The Sedimentation and Pollution Control Act (Art) 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.
■ Refer to Section 12.10.413 of the Durham City/County UDO for groundcover time line requirements.
• Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
120 E. Parrish Street, Law Bldg., I" Floor, Durham, N.C. 27701 + (919) 56"735 • Fax [phone]
www.dconc.gov/indox.aspx?png"180

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
Moore & Alphin, PLLC
Name
3733 National Drive, Suite 100
Street Address
Raleigh NC 27612
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. 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.
3 f (U I z ) Keith Greenwood
Date Type or Print Name
919-669-5372
Telephone Fax nl JTjtle.pr thority -
keithn15ventures.com aN { l , . .
Email !"j Signature
Business Applicant (Provide corporate resolution on siQnatory authori
iPc-t�Ay a Notary Public of the County of .- ( jc'L 1C e
State of hereby certify that _ se L{-
personally carve before me this day and acknowledged that he is i?/1�?1i1�%i�i�� ►'J7�� Jl ��
of / +UZ&4 6y 11 l,U_ and acknowledged, on behalf of � _ �({ �'L�Z@�� L Q
Witness my hand and official seal, this
the due execution of the foregoing instrument.
day of
Notary
My commission expires Oc_-�0{7'—(' s20 Z (
Individual Applicant
I,
State
a Notary Public of the County of
hereby certify that
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personally appeared before me this date and un&� oath acknowledged that the above forna was executed by them.
Witness my hand and official seal, this day of 20
Notary Public
My commission expires V20
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE

Provide a Notarized Item S 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.
3 I ) L vi Keith Greenwood
Date Type or Print Name
919-669-5372
Telephone Fax itle ty
keithc� 15ven#ures.corri
Email r'""ItlirP
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Business Landowner rorov_ide c�orate resolution on si&m authon
1, _ill a Notary Public of the County of w .rlC e
State of hereby certify that (Jd
personally came before me this day and acknowledged that he is , Z
of and acknowledged, on behalf of
Witness my hand and official seal, this
the due execution of the foregoing instrument.
1 day of �' `��
My commission expires _ _ D_%�kp - 5— , 20 Z
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Individual Landowner
1,
State
Notary Public of the County of
personally appeared before me this date and under
Witness my hand and official seal,
My commission expires
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that the above form was executed by them.
SE-03
Rev, 10113