NCC230398_FRO Submitted_20230213

JCN
DURHAM
+ 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: 3100 Umstead Road — Goldman Residence
2. Road location of land -disturbing activity: 3100 Umstead Road Durham, NC 27712
Tax Map - Block - Parcel: 181487 PIN: 0804-63-72-3750
Extension: No
3. Square footage of land to be disturbed or uncovered: 64,826 sq. ft. = 1.488 acres
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Jeffrey and Bailey Goldman
Name
3100 Umstead Road
Address
Durham North Carolina 27712
City State Zip
[phone] n/a ieffcs!oldmanA mail.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.
Jeffrey and Bailey Goldman
Name
3100 Umstead Road
Address
Durham North Carolina 27712
City State Zip
[phone] n/a jeffe2oldmanA mail.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.
■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
201 E. Main St, 5' 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:
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.
Jeffrey Goldman
Print Name
[phone] n/a
Phone Number Fax Number
jeffmoldmanA mail.com
Email Siinature
Bailey Goldman
Print Name
[phone] n/a
Phone Number Fax N r � UtL,�_
j effegoldmanA mail.com ,-�
Email Si ture
Date
t �Z 2023
Date
1, () 16 V1 SZ M , a Notary Public of the County of DuA-h Gk�w,
State of Nc)" \ hereby certify that Jeff Goldman
personally appeared before me this date and under oath acknowledged that the above forrn was executed by him.
C \\�ruiiinrtrnrn
Witness my hand and official seal, this day of Q,YIUaVv" 2:3 20
L Notary Pub is O'er
of ryPublic Founyym
M commission expires % M01COmm Exp N`
Y p r)QQ� V� oS 20 Z74- O '05-2027
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a Notary Public of the County of tx�yv-0.�
State of (IOVAh hereby certify that Bailey Goldman
personally appeared before me this date and under oath acknowledged that the above form was executed by her.
Witness my hand and official seal, this
12_1?
My commission expires dcoluct V' 20
day of t.LG 0 �uuurrn
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u lic ; _j Durham r
M Comm.
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Z o l-05-2027
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE `')i/,rrr fill `���`