NCC231549_FRO Submitted_20230522

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
BEO FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
"` WITH LANDOWNER CONSENT FORM
• 1881
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: Falls Village Amentiv Center Extension: Yes or No
2. Road location of land-disturbing activity: Baptist Road(NCSR 1807)
Tax Map-Block-Parcel: PIN:
3. Square footage of land to be disturbed or uncovered: 12.37 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):
Stanley Martin Homes LLC
Name
4020 Westchase Blvd#470
Address
Raleigh,NC 27607
City State Zip
919-724-0624 [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.
Stanley Martin Homes LLC
Name
4020 Westchase Blvd#470
Address
Raleigh,NC 27607
City State Zip
919-724-0624 [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,5th 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:
Brian Ketchem
Name
4020 Westchase Blvd#470
Address
Ralei;h. NC 27607
City State Zip
919-724-0624 [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.
2� 2.023 614►i ) Lek
Dat T or Print Name
°1l�_ - o1y t✓eera(? Ol I-v4 j
Telephone Fax Tit Authority
Email Sig
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Business Applicant(Provide corporate resolution on signatory authority)
I, j 64 Vt C( E_4L. ,a Notary Public of the County ofVi
J .
State of N L ,hereby certify that �fni/\ .kCrk. V
r
personally came before me this day and acknowledged that he is VX/(0-01e° 0 k"
of S)TAykl t,9 YY ,/\40/001,112nd acknowledged,on behalf of S. --t i4' 64,4 ,n %.g i,+;A. p iv1/4.0
the due execution of the foregoing instrument.
Witness my hand and official seal,this I-• day of m k, ,20 ,3
4No Public
My commission expires ."4710 2.3 ,36— .
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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 \`\\ K I I it yr ail/,
My commission expires 20 v 4,o Q• a.
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE - ?° s�0°..��• �1.
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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.
42/23 3 (IU)
icit-rutrwk
Date Type or Print Name
.12 loVy D(reitC-re4 Or LAAJo
Telephone Fax Tit uthority
Email Sig
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Business Landowner(Provide corporate resolution on signatory authority)
I, is atiit\ X— ,a Notary Public of the County of VI
/ .,��, ,
State of Pi ' ,hereby certify that (6YN Gw\ L �VY\
personally came before me this day and acknowledged that he is D\cc. ' 0C W
of Sir► '"`{ I r VN 4 IN\k/ yt1Q Wand acknowledged,on behalf of S ,4_b i Y4.41 et+U Y x Li
i
,the due execution of the foregoing instrument.
Witness my hand and official seal,this 'l.. day of i r `INS .,k ,20 2.
^Z Nor Public`,L
My commission expires 3 _,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
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