NCC220991_FRO Submitted_20220308

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: NC 55 and H
2. Road location of land -disturbing activity: NC Highway 55 and HOp_son Road
151303, 151290, 151278, 151275, 151271, 0727-61-24-9165, 0727•04-72-8558. 0727.04-82-9266, 0737-03-12-0698,
0737-01-43-4364, 0737-03-11-35620, 0737.03-11-6682,
Tax Map - Block - Parcel:151272 151274 213507 213508, 154056 PIN:0737-11.60-1224.DW, 0737-20-29.3775, 0737-03-21.4913
3. Square footage of land to be disturbed or uncovered: 6,950,870 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):
Scannell Properties #539 LLC
Name
8801 River Crossing Blvd., Suite 300
Address
Indianapolis Indiana 46240
City State Zip
[phone] andys _scannellproperties.com
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.
Scannell Properties #539 LLC
Name
8801 River Crossing Blvd., Suite 300
Street Address
Indianapolis Indiana 46240
City State Zip
[phone] andys[aD_scannellproperties.com
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, 5ch 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:
COGENCY GLOBAL INC.
Name
212 South Tryon Street Suite 1000
Street Address
Charlotte NC 28281
City
Telephone
State
Fax
Zip
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.
March 4, 2022 Marc D. Pfleging _
Date Type or Print Name
[phone] _ Manager _
Telephone Fax Tjtle_prA
thority, '--�
Email
Signature
*+*++++++r++++r**+++++++++rrrr*rrrr++++++++++r+rr+r+++r+r+*++++*+++r+rr+++++*++*++++++++++++++++++++r++++++++++++++*+++r++++++**+*+
Business Amilicant (Provide corporate resolution on signatory authority)
I, �T�[_ QrSf1rJ , a Notary Public of the County of Marion
State of Indiana
hereby certify that Marc D.
personally came before me this day and acknowledged that he is Manager
of Scannell Properties #539 LLC and acknowledged, on behalf of Scannell Properties #539, LLC
the due execution of the foregoing instrument.
Witness my hand and official seal, this 4th
My commission expires Z/Oo -i'Anl-'15
day of March
&I
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Individual Applicant
I,
State
a Notary Public of the County of
hereby certify that
2022
Notary Public, State of Indiana
HAMILTON COUNTY
1-iC0Y�18�8IGR+�iIY 01hGri Fa4'l84$
My Commission Expires
November 23. 2024
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.
Date
Type or Print Name
Telephone Fax Title or Authority
Email Signature
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l3us ness Landowner {Provide corporate resolution on sianatory authorit
I, , a Notary Public of the County of
State of , hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of
20
Notary Public
My commission expires 20
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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 day of 120
Notary Public
My commission expires 20
5E-03 Rev.07106