NCC231390_FRO Submitted_20230512

IURHA JCN
N Durham City/County (Office Use Only)
1145-5
I Sedimentation and Erosion Control
ENE
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: HUB RTP Block A2-1 Life Sciences Building
2. Road location of land-disturbing activity:_SE Corner of Elion Drive and Sancar Way located in HUB RTP
Tax Map-Block-Parcel: 231007 PIN: 0748-00-90-5520
3. Square footage of land to be disturbed or uncovered: 1.43 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):
_Durham Block A2, LLC
Name
_60 State Street 35th Floor
Address
_Boston MA 02109
City State Zip
_919-616-1531
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.
_Durham Block A2,LLC
Name
_60 State Street 35`h Floor
Street Address
_Boston MA 02109
City State Zip
919-616-1531
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.
201 E.Main St,5`h Floor,Durham,N.C.27701 •[phone]•Fax[phone]
www.co.durham.nc.us/ceng

• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Joe Van Saun
Name
3170 Elion Drive
Street Address
Durham NC 27709
City State Zip
617-833-5275 [e-mail]
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.
_February 23,2023 Joe Van Saun
Date Type or Print Name
_617-833-5275 Partner,Accounting& Fi ance
Telephone Fax Title o iori
[e-mail]
Email Signature
Business Applicant(Provide corporate resolution on signatory authority)
I,_Susan Mary Jacobs ,a Notary Public of the County of Wake
State of_North Carolina ,hereby certify that Joe Van Saun
personally came before me this day and acknowledged that he is Partner,Accounting&Finance
of_Longfellow Real Estate Partners_and acknowledged,on behalf of_Durham Block A2,LLC
,the due execution of the foregoing instrument.
Witness my hand and official seal,this 23 day of February ,2023
SUSAN MARY JACOBS ` +'
NOTARY PUBLIC S Wake County Notary Public
My commis ion expire'lorth Carolina ,20
My Commission Expires February 18,2028
*********************************************************************************************************************************
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.
_February 23,2023 Joe Van Saun
Date Type or Print Name
617-833-5275 Partner, Accounti g& inance
Telephone Fax Titl- = on
[e-mail]
Email Signature
**#*****************,**************************************************** ***********K >k>fi>t****%k%k** **********,,**kF *****************
Business Landowner(Provide corporate resolution on signatory authority)
I,_Susan Mary Jacobs ,a Notary Public of the County of Wake
State of North Carolina ,hereby certify that Joe Van Saun
personally came before me this day and acknowledged that he is__Partner,Accounting&Finance
of Longfellow Real Estate Partners and acknowledged,on behalf of Durham Block A2,LLC
,the due execution of the foregoing instrument.
Witness my hand and official seal,this 23 day of February ,2023
SUSAN MARY JACOBS �l
NOTARY PUBLIC \ •1_,
Wake County Notary Public
My commissiorx s North Carolina
Tre ,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