NCC230573_FRO Submitted_20230303

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 Pen -nit 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: GRIFFIN PLACE- NORTH Extension: Yes or No
2. Road location of land -disturbing activity: APPROX. 618 LF EAST OF THE INTERSECTION OF E. GEER ST. AND
JUNCTION RD.
Tax Map - Block - Parcel:
3. Square footage of land to be disturbed or uncovered: 27.05
PIN: 0842-88-02-0119
4. List below the landowner of record. Each landowner must complete Item 8
(If there are multiple owners, please list on a separate page):
TOR GRIFFIN, LLC
Name
2930 POCOCK RD.
Address
MONKTON, MD 21Ill
City State Zip
410-459-8401 N/A fred(a)tenoaksrealty.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.
TOR GRIFFIN, LLC
Name
2930 POCOCK RD.
Street Address
MONKTON, MD 21111
City State Zip
410-459-8401 N/A [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.
■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
201 E. Main St, 5tn Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
vnvw.co.durham.nc.us/ceng

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
L'--C_
Name
I&. M+nG �� Lt SfG ZOZ�
Street Address
epk'eaj ZZ7
City j State Zip
84S•424•61a77 X i<- A(Ss • 3< 55 caQfN. C-e00 e/toC'_0 ctrv�cc�_�_o,•
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.
I 123 rrml S
Date I I Type or Print Name
4(0•g51, $90i 14va'�►ofrze�.� J�'�5A�1, %�JiL �ri �GC.t
kS l
Email
Business Applicant (Provide corporate resolution on siEnatory authori
or
I, (IMLA r) r„ , q t &� , r I ba a Notary Public of the County of . c sLjt\ +'
State of AN_�__o n, -,hereby certify that 2�d �'he CV4 A s
personally came before me this day and acknowledged that he is �!� ���'_�.3' ��o►
of �iJ'�Z ,� , l .L and acknowledged, on behalf of GNr� f+i n ,
, the due execution of the foregoing instrument.
Witness my hand and official seal, this 1 " day of can UL a_r -4 20 `Z3
C, , al L 07V'Z',A� Vj'-'r'_L
Notary
My commission expires 0.4-e rn p<-, 20 `L
Individual Applicant
I, , 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
My commission expires
20
day of
Notary Public
20
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
CAITLYN ANNE GRECKI WOOD
NOTARY PUBLIC
CARROLL COUNTY
MARYLAND
MY COMMISSION EXPIRES NOV. 07, 2026

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.
110 NOz3 E=ej S (n�����
Date �— Type or Print Nam
y10.4J-S40( A.,f1,ar_;z.1 �rso� - lug car; ff,'.', u-r--
Business Landowner (Provide corporate resolution on sienatory authori
1, l _ a_�n Ace a Notary Public of the County of
State of A(0 I\ ckr, J hereby certify that 'Lc (;�
personally came before me this day and acknowledged that he is
Of 7�70'\Z . a C'm 11, C , 'e . and acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of � VU AAA 20 u
Notary Pu lic
My commission expires 20.
Individual Landowner
I, , a Notary Public of the County of
State
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.
My commission expires 20
5E-03
day of 20
Notary Public
Rev.07/06
CAITLYN ANNE GRECKI WOOD
NOTARY PUBLIC
CARROLL COUNTY
MARYLAN D
MY COMMISSION EXPIRES NOV. 07, 2026