NCC223180_FRO Submitted_20220909

JCN
■ Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITYIOWNERSHIP 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
I. Project name: Durham VA Facility
2. Road location of land -disturbing activity: 3114 Croasdaile Dr Durham. NC 27705
Tax Mall - Block - Parcel: 130468 PIN: 0812-58-42-0339
3. Square footage of land to be disturbed or uncovered: 0•85
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
VAF 3114 CROASDAILE DR LLC
Name
1554 N BEVERLY DR
Address
Beverly Hills CA 90210
City State Zip
804.339,1366 NIA [e-mail]
Telephone Fax Email
5. List the person or entity financially responsible for this land -disturbing activity: The financially responsible parry 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.
VAF 3114 CRCASDAILE DR LLC
Name
1554 N BEVERLY DR
Street Address
Beverly Hills CA 90210
City State Zip
804.339.1368 N/A [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, at1 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, 511 Floor, Durham, N.C. 27701 • [phone] ■ Fax [phone]
nmtiv.co. d a rltant.itc.uslceng

■ Flan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
G. For business applicants, list below the North Carolina registered agent for the financially responsible entity;
Steven Cody
Naive
1554 N BEVERLY OR
Street Address
Beverly Hi11s CA 90210
City State Zip
804 339.1368 N/A scody®catalystcap.com
l'elephone
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: ( I ) 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.
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LAND ❑ISTURBING PERMITS ARE NON -TRANSFERABLE
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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 Iisted in Item 5.
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