NCC222956_FRO Submitted_20220818

DURHAM
COUNTY
IMP
1881
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: Fowler Tract — Phase 1 Mass Grading
2. Road location of land -disturbing activity: 705 Doc Nichols Road Durham NC JPrej Entrance Lai 35.955165 Lon-78.7928U2
Tax Map - Block - Parcel: 193344, 193361 PIN: 0860-03-33-2395, 0860-01-31-5371_
3. Square footage of land to be disturbed or uncovered: 3,136,320 sf (72 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):
Clayton Properties Group, Inc.
Name
2521 Schieffelin Road. Suite 116
Address
Apex NC 27502
City State Zip
919-901-2595 bclark mun o.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.
Clavton Properties Group. Inc.
Name
2521 Schieffelin Road
Suite 116
Street Address
Apex
NC 27502
City
State Zip
919-901-2595
bclarkAmungo.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, 5"' Floor, Durham, N.C. 27701 r [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:
Casev Heim
Name
3T3 ,National Dr. Suite 100
Street Address
Raleicth NC 27612
City State Zip
919-787-8812 case mooreal hin.com
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.
Adam Speiran_. _ . .
Date Type or Print Name
919-303-8525 Assistant Secretary
Telephone Fax Tit lS of Authority
Email
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Business A D p I i c a n t rovide co orate resolution on si nato authorit
I, �Y111 , a Notary Public of the County of V�
State of hereby certify that
personally came before me this day and acknowledged that he is
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the due execution of the Foregoing instrument.
Witness my hand and official seal, this day of 20
KIMBERLY DA K N tary Public
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Individual Applicant
I,
State
, a Notary Public of the County 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
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.
!1
Adam Speiran
Date I Type or Print Name
919-303-8525 Assistant Secreta
Telephone Fax Title o} Authority
[e-mail]
Email
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personally
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Witness my hand and official seal, this % ! - - - day of 120 �•�
KIMBERLY DARK // �� ,� t/, Notary Public
Notary Public, iNqttfhflafstliVjj8rxpi s 5 �P ,20;
Wake County
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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
SE-03 Rev.07/06