NCC230994_FRO Submitted_20230414

JCN
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: I 1 �� rz C �C 5`C c ')
2. Road location of land-disturbing activity: ` b G ° ' v c' r-"-"" t
Tax Map-Block-Parcel:
3. Square footage of land to be disturbed or uncovered: 3 '2_7 12.)�. 11.1'1 -;F
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
(M(. '12-'i `aFj "Cm s 44-
L
Name
lootik c — (n e w z !� v� 3��: �-� -35`6
Address
City State Zip �u
s-(3 -327-66i 1 �u �Lio r 5 vvlc r- 'fir�5E'
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-
distiubing activity andfor(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.
Name y�' �y� + _�
� l3C) � C I (3.�� G` �e - S� L�c r l IJ✓i V 't_ � �M'k 35 V
Street Address
City State Zip
q q 2, 3 Z 7 n el ci 1 l (/',) 5 6.) Oil c t'4,r.,,,
Telephone Fax Email
The Sedimentation and Pollution Control Act(Act)and the Durham City-County Unified Development Ordinance(Ordinance)
includes,bill 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.
■ Refer to Section 12.1O.4B of the Durham City/County UDO for groundcover time line requirements.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedinientatiom
120 E.Parrish Street,Law Bldg.,l`t Floor,Durham,N.L.27701 is(919)560-0735•Fax[phone]
www.dcour.govrmdex.asi n?page=t80

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.
"3//'7 7 2.--2— LAI l' ( 1 i'cx..,0^ 04 IN o„,-/-, 5
Date Type or Print Name
Telephone Fax '/7 r `11
Email Signature
Business Applicant(Provide corporate resolution on signatory authority)
I, ,a Notary Public of the County of
State of ,hereby certify that
personally carp-before me this day and acknowledged that he is
of and acknowledged,on behalf of
,the due execution of the foregoing instrument
Witness my hand and official seal,this day of ,20
Notary Public
My commission expires ,20
******4-b*********************Y*RR1=*6eF*-4,4***i*fiS********7rtc#,*4=f. ****4K8-c****=k*,P.-1,e.•#mid****R**i**Vi.44,***R *****************#fii--
Individual Applicant
I, L tI e rt •4- C• /�L
'�,a Notary Public of the County of it..4 e C/e / -5 yet .
State of A/ 4- ,hereby certify that ��•t l• e11�L! r �✓OI�Y+ s
personally appeared before ure this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal,this i 7 4" day of 41,1 L(.tf / ,20 !-`
c .. i
Notary Public I{IIiligiLSOA Co,,00®
b .
My commission expires .3 �' 20 0�- `0,0©C� ,
tIOTA,c ciA
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE %e : o. •o :0m:
��g�RG G°` 011•

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner,I provide my censer for land-disturbing activities to occur on the property listed in
Item 2 by the person or entity listed in Item 5.
4 / 1i/2Z 7 j / (' V"f J!li 5
Date Type or Print N.
1y -j,-327,6o( q ip La....cl lG.o,I. ; 5 i k; e.1
Teleptnktihone Fax Ti or_ ity i `4
Email Signature
Business Landowner(Pro corporate resolution on signatory authority?
I, lit I: G. C . 41,a Notary Public of the County of me de It n.
State of ,hereby certify that hi ; 1 l' A.nt. ''., Orel S
personally caw&before me this day/and ac.: >ledged that he is l/P
of LJ6.4 4c5£tiS!-t1Ow- and acknow _-i,on behalf of
.i- due execution of the °1 •-_••i ng instrument.Witness my hand and offici 1,this /n44- day of ,20
Notary Public
My •i . .on expires ,20
****.#*i-#.*k%**44*4.*******.***.***..i4 44o-bRo-64.4.114s*********i«YES.**1.k.b864,1,-****4-1-64 **44RbrR.-4x#4.********si.Y1,-RS.R******6-{.M44,1-1.***
Individual Landowner ,,,
I, C.O r i• a C • Iib .k,a Notary Public of the County of /-{e ck I ell 4 u+C
State of /V hereby certify that �V• 1•Ge r•- 4 VYI S
personally appeared before me ibis date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal,this t 1 L day of S i.{$f" ,20 2?--
C •Thi ---..
/ Notary Public
My commission expires 3/ Z _ 20 2-•-i- 'illl®f90// mBool
oFtAK
0.
/// ,`�1�`t.• c�F `• Z Rev.10/13
SE-03 PI 2': •`e' r 0'
[[ • h
:Z.,©:.--% I �/• :0
O . ,e c.)
•'�
•®-,�CKL Eh��'• A01