NCC230104_FRO Submitted_20230113

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: Olive Branch Sewer Outfall
2. Road location of land -disturbing activity: Olive Branch Road (lattitude 35.959600, longitude-78.768230)
Tax Map - Block - Parcel:
PIN: 0860-86-07-1796
3. Square footage of land to be disturbed or uncovered: 81,189 S.F. (1.86 AC.)
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Bethesda Association, LLC
Name
10030 Green Level Church Rd.
Address
Cary North Carolina 27519
City State Zip
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.
Pulte Home Comoanv. LLC
Name
1225 Crescent Green Drive, Suite 250
Street Address
Cary NC
27518
City State
Zip
919-816-1146 n/a
chris.raughleyCa�pultegroup.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, 5th Floor, Durham, N.C. 27701 e [phone] 0 Fax [phone]
www.co.durham.nc.us/ceng

• Plan 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:
Name
Street Address
City State Zip
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.
zi-t I vL Chris Raughley _
Date Type or Print Name
Ci A, kIC.t VP Land Development
Telephone Fax Till e or Au ty
Email
Signature
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Business Applicant (Provide comorate resolution on sianatory authorit
I, Sam on C.. �Idc� �+ c c_ , a Notary Public of the County of kl a k--e.- rr _
State of N C, hereby certify that C k e
personally came before me this day and acknowledged that he is V 1 C Sre , c'i— /}
of f_Ck eN ck 021P,e.�m� and acknowledged, on behalf of fp L;, l k—t.-
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of 1:�_6rLka Yr V �20 aC
--� Notary Public
My commission expires cJ�. v 20.
Individual Applicant
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a Notary Public of the County ofC�D�c"�
State of hereby certify that Yen. cn
r
personally appeared before me this date and under oath acknowledged that the above form was executeA bXtt M.
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Witness my hand and official seal, this day of % L , 20
Notary Public
My commission expires 20
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, 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
Telephone
Fax
Type or Print Name
Title or Authority
Email Signature
Business Landowner (Provide corroorate resolution on sienatory authori
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 120
My commission expires 120
Individual Landowner
I,
State
Notary Public
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 day of , 20
My commission expires
20
Notary Public
5E-03 Rev.07/06