NCC220787_FRO Submitted_20220216

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: 120 Broadway Street
2. Road location of land -disturbing activity: 118 - 120 Broadway St., 706-710 North St.
Tax Map - Block - Parcel:
PIN: 0831-05-09-2383
3. Square footage of land to be disturbed or uncovered:
54,928
4. List below the landowner of record. Each landowner must
complete Item 8.
(If there are multiple owners, please list on a separate page):
Broadway Townhomes, LLC
Name
2201 Wisconsin Ave NW, Suite 226
Address
Washington DC
20007
City State
Zip
202-922-6540 N/A
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.
David Gorman
Name
2201 Wisconsin Ave NW,
Suite 226
Street Address
Washington
DC
20007
City
State
Zip
202-922-6540
[e-mail]
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.
■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
201 E. Main St, 51h Floor, Durham, N.C. 27701 e [phone] . Fax [phone]
www.co.durham.nc.us/ceng

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
_Chappell
Name
_910 Tryon Hill Drive, Suite 100
Street Address
Raleigh NC_
27603
City State Zip
919.737.2247 [e-mail]
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.
_9/13/21 David Gorman
Date Type or Print Name
202-922-6540 Principal
Telephone Fax Title or Authority
[e-mail] /
Email
Signature
Business Anulicant (Provide corporate resolution on signatory authority)
I, 1 a Notary Public of the County of
State of
hereby certify that
personally came before me this day and acknowledged that he is
of
Witness my hand and official seal, this
My commission expires
and acknowledged, on behalf of
, the due execution of the foregoing instrument.
20
day of
Notary Public
Individual Annlicant
I, , a Notary Public of the County of
State o
hereby certify that
20
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 120.
My commission expires
20
Notary Public
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE

Provide a Notarized Item H for each landowner listed in Item 4.
!i. Land Dnner 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,
9113121 Broadway Townhomes, LLC
Deft Type or Print tame
Managing Member
Telephone Fax Tile or uthorisy
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Email signafure
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Business Landowner {tmvidc comoeate resolution on sigaMM audwrity)
1, fir: n GIC w .r a Notary Public of the County of �►�lad•l �-r ,
State of hereby certify that
personally came before me this day and acknowledged that be is _ 0(?JV -Cy
of ) 2 O and acknowledgLii, on behalf of paw +_(fit Gf T .n h C �►►-C 5 LtL
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the due execution of the forcgoing instrument,aL
Witness my hand and official seal, this 1 3 day of 55 si .i..a 20 ►` A : _ •.�r.
Notary Public G f ' E U
My commission expires 11� , 2p ';. z 0. 1 e '
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State of
a Notary Public of the County of
hereby certify that
personally appeared Wore me this date and under oath acknov.lcdgcd that the above form was executed by them.
Witness my hand anti official seal, this .. day of
Nularn Public
My commission expirrs 20
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