NCC230559_FRO Submitted_20230303

DURHAM
COUNTY
M'
• 1ti81
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 permiace of the obligation to obtain any other licenses, permits and approvals as inny be raluired by Federal, State,
C0111tty Or Municipal governments. This office must be notified in writing of any change to the inturtnation on this 1or,n.
PLEASE TYPE OR PRINT
1. Project name:
2. Road location of land -disturbing activity:
Tax Map - Block - Parcel:
3. Square footage or land to be disturbed or uncovered: 4• 3AC,
rt
ogto_ol-lq- 8o1q1oS10_o1•l$-7Yo2lo�
PIN: O I - -0l
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners: please list on a separate page):
... _
Name
1610 SmAtkGl St(ce
Address
Mo-rPre-S
City State Zip
o S4A ox4rinc+'i 10 � &rb,%
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 ]and -
disturbing activity andlor (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.
V t o v-
Nance
G U S to 1, (,6n_r_6s SArtet Sty i e- C
Street Address
r Fra s b r'
City Q State Tin
O'
Fax
xtrH c rJi+'1 . GriM
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 tile financially responsible party_
• Maintain a set of approved sedimentation and erosion control plans, if required, oil site.
■ Display permit on site.
■ Understand and 11nple331cnt any required plan, including the construction sequence and details.
■ Inspect, maintain and repair seduuentation and erosion control measures, especially after rainfall events.
• Refer to Section 12.10.413 of the DurItam CitylCounly UDO for groundcover time line requirements.
• flan and conduct all land -disturbing activity so as to prLwent off site sedimentation.
120 E. Parrish Street, Law Bldg., 1" Floor, Durham, N.C. 27701 • (9I9) 560-0735 • Fax [phone]
w►►w.d con c.gov/1ndc1.nspx?p11gN18 o

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
Ati
+2 f
Name " , j '
(-aK� Ct s tdi-r e. a 00
Street Address
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.
Date
' -3 0l
Type or Print Nari
Signature
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Business Annlicant (Provide corporate resolution on si2natory authorit
I, a Notary Public of the County of wi be r F U r
State of G xee-- , hereby certify that I i t h ►1 �Ce� c _
personally came before me this day and acknowledged that he is
�bC i r
of Ot„r%P,m.Owr> and acknowledged, on behalf of V 1 I�Ot �{r►ry►os m
LL the due execution of the foregoing instrument.
Witness my hand and official seal, this day of �� ✓1 L. ��
6 Notary Public
My commission expires �/ /� , 20.
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Individual Applicant
I, a Notary Public of the County of
State of hereby certify that
TENNESSEE
!VOTARY
eoO SM
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal,
My commission expires
20
day of _
Notary Public
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
20

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.
OCo --F' im'h o► c 1�
Date Type or Print Name
Telephone Fax Title or
,�tqvl
ail Signature
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Business Landowner (Provide corporate resolution on sienatory autharit
I, ke r , a Notary Public of the County of Q tAke_ r F& r
State of -Te n n eSS e e- hereby certify that CAC
personally
�� came beforemethis day and acknowledged that he is A Oi i— _
of l/ u6v1 C, LL C and acknowledged, on behalf of —T, �A r\A L L
, the due execution of the foregoing instrument.
Witness my hand and official seal, this _ is — day of
L Notary Public
My commission expires , 20.
Individual Landowner
I, , a Notary Public of the County of
State of , hereby certify that
-- STATE
eF
TENNESSEE
i OTP,RY
IDUBLI C
OF RV
[r
C0
M4f. EXPIRES
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
SR-03 Rev.10/13