NCC222876_FRO Submitted_20220811

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: Hollowav Studios
2. Road location of land -disturbing activity: Peachtree Place
Tax Map - Block - Parcel: _ 110532, 110531 _ PIN:0831-09-16-4765 0831-09-16-4553
3. Square footage of land to be disturbed or uncovered: 62 411
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
218 N. Dillard LLC
Name
107 E. Cha el Hill St.
Address
Durham NC 27701
City State Zip
919-949-3863 NIA
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
Perm it.
_Scott Harmon
Name
107 E. Cha el Hill St.
Street Address
_Durham NC
27701
City State
Zip
919-949-3863
[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, 5" Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durham.nc.usheng

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
218 N. Dillard LLC
Name
107 E. Chapel Hill St.
Street Address
Durham
NC 27701
City
State Zip
919-949-3863
N/A
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.
Date t ' -
T.c�L• z�� •38 � .3
.6
Email
Fax
or Print
Title or Authority
Signature
Business Applicant Provide cor orate resolution on signatoU authority)
1, , a Notary Public of the County of
R N1
Du>G4XX�l LZ e
State of N 0— , hereby certify that ae, OZA L-D—se p T'-
personally came before me this day and acknowledged that he is t J p ^
Of 219 X • P& and acknowledged, on behalf of 'Z& IV.
the due execution of the foregoing instrument.
Witness my hand and official seal, this ~
dayof 0e1{011%E-2.20 Z l
`Ind
Notary Public
My commission expires'L� , 20�.
_AND
EM]
bi`fli*�O#1`I�iauntyIndividual Applicant n Expires026
a Notary Public of the County of
State
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 20
My commission expires
20
Notary Public
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner, 1 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
Telephone Fax
[e-mail]_
Email
_Jerald Scott Harmon
Type or Print Name
Registered Agent
Title or Authority
Signature
Business Landowner Provide co orate resolution on signatory authori
I, L D , a Notary Public of the County of—bLa, r—
State of , hereby certify that !R L. D
personally came before me this day and acknowledged that he is 4649&&
of 4 (0 IV �UeTt44) UAL and acknowledged, on behalf of Z13 AV, a4y .4 (,L L
the due execution of the foregoing instrument.
Witness my hand and official seal, this J'
day of 20 �1
2 o Notary PRic
My commission expires 20
DAWN BLAND
****No*a** Public. No * r* r
1air*i 4`ou n � 41
Individual Landowner MY Commission Expires
June 27, 2026
a Notary Public of the County of
State
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
20
SE-li3
Rev.07/06