NCC230112_FRO Submitted_20230120

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: KBI Biopharma — Warehouse Reno — Phase II
2. Road location of land -disturbing activity: 1101 Hamlin Road, Durham, NC 27704
Tax Map - Block - Parcel: Block 5008 — Parcel 160396 PIN: 083302888102
3. Square footage of land to be disturbed or uncovered: 36,520 ft2 (0.84 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):
EWE Warehouse Investments XXXIV, LLC & EWE Warehouse Investments XXXIII Ltd.
Name
10165 N.W. 19t" Street
Address
Miami Florida 33172
City State Zip
(919)-620-7786 gtompkins(&kbibiopharm a.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.
KBI Biopharma
Name
1101 Hamlin Road
Street Address
Durham NC 27704
City State Zip
919-479-9898
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, 5th Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durham.nc.us/ceng

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
//-61— /1-t > /)Ad s14 t'4
Name Yld t
�&1 0,
Street Address
J'wM4 /G 2-7'0�
Ci State Zip
ly � 71- i gqg,
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.
Business Applicant (Provide corporate resolution on signatory authority)
1, a Notary Public of the County of Du r � tcrn
State of NI)r-J-7) ar.1 ;vice hereby certify that Gi P!�
personally came before me this day and acknowledged that he is _i_ �� ` t , �r1L"t ;,1 Z' a. t
of t Q; c>PVNrvr i YN k n c, and acknowledged, on behalf of KG l e: � rY\ ct Y\ C—
the due execution of the foregoing instrument.
Witness my hand and official seal, this Url'` day of20 1tU11111JI11A fzz
p
Pu�fl:n
Notary Pub ' WY
Durham
My commission expires '�,e F�Rm &-t' 202. — County
Mtj Comm.. fE{ryxp.
Individual Applicant Rp\,���`��
i, a Notary Public of the County of �p<<r„, III1 n\ \\
State o
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
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. 1
lo`►3,ZZ E-dwa,,t 5as`�n
Date Type or Print Name
3()S �;-Cl3_ Z_-'-zz
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Fax
Atrn c,,.s
Business Landowner (Pro_vi-diet corporate resolution on signatory authority}
I, LV��et��t`iJ �+� a Notary Public of the County of
State of '100ri CIO hereby certify that �u cktdM E[, nAcp/i
personally came before me this day and acknowledged that he is �il Yti�Q Cpf
@WE k9 ��tJ �c�cvtltj L'tT) c>►}- ..
of le J. Uand acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this '�p % day of
V LaI b• 4.nc1 IC IKlvrf I
My commission expires 14�' =:F GNotary Public State of Florida
Commission # HH 167678
,
My COMM. ExPires No�vi29, 2025
�tiWWAI Notary Ann,
Individual Landowner
1, , 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 20
My commission expires
20
Notary Public
SE-03 Rev.07/06