NCC231457_FRO Submitted_20230515

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EEO
WITH LANDOWNER CONSENT FORM
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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:Rollingdale
2. Road location of land-disturbing activity:NC 54 HWY
Tax Map-Block-Parcel:PID: 143644, 143643 PIN:0709-58-00-8003. 0709-57-27-0584
3. Square footage of land to be disturbed or uncovered:213.484.7 SF
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
Rollingdale Investments, LLC
Name
4441 Six Forks Road, Suite 106
Address
Raleigh NC 27609
City State Zip
919.414.4780
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.
Toll Bros., Inc.
Name
900 Perimeter Park Drive, Suite B3
Street Address
Morrisville NC 27560
City State L i p
919.321.4800 [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.
201 E.Main St,5'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:
United Agent Group. Inc.
Name
15720 Brixham Hill Avenue #300
Street Address
Charlotte NC 28277
City Suite Zip
919.321.4800 [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; (I) 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.
05.03.2022 Dan Rossi
Date Type or Print Name
919.321.4800 Vie Presi nt
Telephone Fax T' tori
[e-mail]
Entail . ignature
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Business Applicant f Provide corporate resolution on signatory authority)
I, et- _8dr-eit - .a Notary Public of the County of Stan
' State of c ',hereby certify that aafl ten,S i
personally~came before me this day and acknowledged that he is VI C e ;
of `u`F�` js, t a and acknowledged, on behalf of 7D 11 d /it`S J e.
Ft BpU ' bC._.;. , the due execution of the foregoing instrument.
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Witness uity:ltl T.AaMf%c almeal,this ,�id day of .20 .2
'PUBLIC Notary P he
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My comtSy i Lhtpir %% 57 ,20 27 .
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Individual Applicant,
,a Notary Public of the County of
State of ,hereby certify that
personally appeared before inc 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.
4.28.22 Rollingdale Investments, LLC
Date Type or Print Name
919-389-7595 member
Telephone Fax Ti}e�or A thori
[e-mail] J
Email gignature
Business Landowner(Provide corporate resolution on signatory authoritY) 011111/14/
I, ArIbra $ne5 ,a Notary Public of the County of *dnVi>\£. NON
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w;n 'L iS
State of �(� ,hereby certify that -SA/ Sdell _ �0:# NOT F•ill 0
personally came before me this day and acknowledged that he is frtertlt !ar G'_ Cie :`,:
1 i��s Cis 'V
of kb\\t ct`e, IMie54tteAS�II(and acknowledged,on behalf of % {F•;?23 ...••��`:
,the due execution of the foregoing instrument. �°�irtC�l1 1 , `,``�
Witness my hand and official seal,this yarH day of Mai
,20 22-
Notary Public
My commission expires L0-11 ,20 Zits .
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