NCC231211_FRO Submitted_20230426

Durham City/County (Office Use Only)
Sedimentation and Erosion Control JCN
IP 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: Biogen Gene Therapy
2. Road location of land-disturbing activity: Development Drive and Davis Drive
Tax Map-Block-Parcel: 154048 PIN: 0737-82-4964.DW
3. Square footage of land to be disturbed or uncovered: 914,760 SF(21 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):
Biogen US Corporation
Name
225 Binney Street
Address
Cambridge MA 02142
City State Zip
919-993-6882 [e-mail]
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.
Biogen US Corporation -Ashley Franchi
Name
_225 Binney Street
Address
Cambridge MA 02142
City State Zip
919-993-6882 [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,5th 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:
United Agent Group Inc.
Name
15720 Brixham Hill Avenue#300
Street Address
Charlotte NC 28277
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.
Date Type r Print Name
Telephone} / Fax _ Title or Authority0, Ua c. . y6 y�'
Email Signature
Business Applicant(Provide corporate resolution on signatory authority)
I, bo n ‘t_ S C c . ,a Notary Public of the County of 5 Lt - -C-0 1`�
State of (�'' C ubt_fES ,hereby certify that (Y1 -Ct t I p p m bw C
personally came before me this day and acknowledged that he is V' 2 T(C a,),,cc.f
of i 0561 LA() C ;PLY0A 01 and acknowledged,on behalf of Cc C(1;f1 u;CA (
M 6 �S Gc., i-e. ,the due execution of the foregoing instrument.
Witness my hand and official seal,this I S day of 5g1eN1 b ,2 1
Notary Public
My commission expires U ,20 2 ?3 .
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 day of ,20
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.
( lam( M , CLJ
Date ? Type or Print Name
Telephone
G Fax Title o -A�thonty
vs,
Email Signature —
Business Landowner(Provide corporate resolution on signatory authority)
I, ?01, -e- c CC e 7 ,a Notary Public of the County of 5 A-(. 1\L-
State of MOL(SaCJ 2*[3 ,hereby certify that (Yl k 0-A e 1 bO. \Ca e k
personally came before me this day and acknowledged that he is V P. 4- i
of rJi peke U S CL`r-r �rck* f\ and acknowledged,on behalf of (� �l n 14\1,J c ft
c� m G S Q_-V\l,l -f-\S ,the due execution of the foregoing instrument.
Witness my hand and official seal,this 15A- day of 5t toff ,202
Notary Pub c J
My commission expires - `� ` , ,20 ) .
Individual Landowner
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 day of ,20
Notary Public
My commission expires 20
SE-03 Rev.07/06