NCC223523_FRO Submitted_20221013

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:
Sport Durst Jeep Durham
2. Road location of land -disturbing activity:
Tax Map - Block - Parcel: 139325
4511 Durham Chapel Hill Blvd
3. Square footage of land to be disturbed or uncovered:
0800-04-75-9017
PIN:
3.09 acres - 134,600 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):
MKD Properties LLC
Name
4511 Chapel Hill Blvd
Address
Durham NC
27707
City State
zip
828.649.1344 -
[e-mail]
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.
Sport Durst - MKD Properties LLC
Name .
4511 Chapel Hill Blvd
Street Address
Durham NC
27707
City State
zip
828.649.1344 -
[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.
201 E. Main St, 51h Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
wvvw.co.durh am.nc.us/ceng
7

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 b/{ the erson or entity listed in Item 5.
VA
Business Landowner (Provide comorate resolution on signatory authority)
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
Witness my hand and official seal, this
My commission expires
the due execution of the foregoing instrument.
day of
Notary Public
20
20
Individual Land wner
I a Notary Public of the County of �-
1
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 �riQ 120 0l
! q MARY JO H CONWAY
My commission expires 20 NOTARY PUBLIC
Durham County, NC
SE-03 Rev.07/0
Exp. Dec 15 2026