NCC230331_FRO Submitted_20230207

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: W. Club Apartments
2. Road location of land -disturbing activity:
Tax Map - Block - Parcel: 105943
Tax Map - Block - Parcel: 105942
Tax Map - Block - Parcel: 105937
Tax Map - Block - Parcel: 105935
Tax Map - Block - Parcel: 105934
Tax Map - Block - Parcel: 105933
Tax Map - Block - Parcel: 105932
Tax Map - Block - Parcel: 105931
Tax Map - Block - Parcel: 105930
W. Club Blvd and N. Duke St
PIN:0822-85-41-6782
PIN: 0822-85-34-3709
PIN:0822-85-11-8632
PIN:0822-85-03-9921
PIN:0822-85-04-9461
PIN: 0822-85-04-9991
PIN: 0822-85-15-0441
PIN: 0822-85-15-0981
PIN: 0822-85-16-1331
3. Square footage of land to be disturbed or uncovered:_292,458 SF_(6.71 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):
_Rosewalk Associates, LLC
Name
_300 S. Tryon Street, STE 200
Address
_Charlotte
City
_704.358. 1000
Telephone
NC_
State
Fax
2$202
Zip
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.
_Rosewalk Associates, LLC`
Name
_300 S. Tryon Street, STE 200
Street Address
_Charlotte NC_
City State
_704.358. 1000
Telephone Fax
28202
Zip
Email
201 E. Main St, 5"' Floor, Durham, N.C. 27701 . [phone] • Fax [phone]
www.co.durham.nc.us/ceng

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.
6. 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.
_12/7/2022
Date
_704-557-2452
Telephone
[e-mail]
Email
Fax
Stephen McClure
—Stephen
or Print Name
CEO
T�it1e or Au�lio�rj�
Signature
1, a Notary Public of the County of
State of -,hereby certify that
personally came Ibefore me this �daay�a�nrd�^acknowledged that he is J � �
of �b UUQ_ __ Y SIC)LA&V1 ULand acknowledged, on behalf yT. 614 �.f I L1_
the due execution of the foregoing instrument.
Witness my hand and official seal, this day ❑ 20
Pub[ i c
My commission expires. had �5 20"
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A E ORMOND
**************************************************************************************eenburg County
Individual Applicant mission Expires
il 15, 2026
a Notary Public of the County of
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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
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.
12/7/2022
Date
_704-557-2452
Telephone
smcclureCspectrumeos.com
Email
Fax
Stephen McClure
Type or Print Name
CEO
Title or Authority ,
Signature
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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
My commission expires
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Notary Public
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5E-03 Rev.07/06