NCC231541_FRO Submitted_20230524

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
O Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
NC
1881 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: Hemlock
2. Road location of land-disturbing activity: Hemlock Ave
Tax Map-Block-Parcel: Bernice Mason Subdivision: Block A-Lots 2-7; Block B-Lots 1-4: Block C-Lots 11-17
PINS: 0820-16-94-4360; 0820-16-94-5218; 0820-16-94-5455; 0820-16-94-5594; 0820-16-94-6641; 0820-16-94-6697; 0820-
16-94-7797;0820-16-94-5895:0820-16-94-4828:0820-16-94-2963;0820-16-94-2698;0820-16-94-4615i
3. Square footage of land to be disturbed or uncovered:217,800
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
B. Wallace Design& Construction LLC
Name
3200 Sandy Creek Drive
Address
Durham NC 27705
City State Zip
[phone] g_ary�a bwal lacebuilt com
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.
B. Wallace Design &Construction
Name
3200 Sandy Creek Drive
Street Address
Durham NC 27705
City State Zip
[phone] gary t�i bwallacebuilt.corn
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.
201 E. Main St,5th Floor,Durham,N.C.27701 •[phone]•Fax[phone]
www.co.clarham.nc.us/ceng

• 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.
6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Gary Wallace
Name
3200 Sandy Creek Drive
Street Address
Durham NC 27705
City State Zip
[phone] ary_(t)bwallacebuilt com
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. 1
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 t n or dec. ' made by the Sedimentation and Erosion Control Office.
Ga • Wallace
Date Type or Print Name
(919)60 35 Manager
Telephone Fax Title or Authority
Garv'a!bwallacebuilt.com
Email Signature
Business
ssApplicant(Provide corporate resolution on signatory authority)
1. • ec iS4►r6L L'al s�'1 .a Notary Public of the County of Wa
State of 1\iv((l-Al'.Q(c�)►r0.. . hereby certify that q I& I'a eZ
personally came before me this day ands acknowledgedle that he is Ala naa Dr
of �• �d I 10 m P#,S ip Q l..trS neacknowledged.on behalf of J�. I/a Q, (bps 01 r an a.: N M Cristina Colon , the due execution of the foregoing instrument.
Qkn.�,`� itne t a� official seal,this nr C.0 �of �-��; � 20 013
My Commission Expires November 20,2026 ,//�
otary Public /'
My commission expires )1- v2 6 - a0a(Q ,20
Individual Applicant
1. ,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 ner Consent. As a landowner. I provide my consent for land-disturbing activities to occur on the property listed in
Item the perso r e ti ed in Item 5.
Gary Wallace
Date Type or Print Name
(919)606-2 Manager
Telephone Fax Title or Authority
gary car bwallacebuilt.com
Email Signature
Business Landowner((Provide corporate resolution on signatory authority)
I, ^1 efiS4gr QL l-v)6i1 .a Notary Public of the County of k/GY L.
n/State of a dQ(.)&na., . hereby certify that `?exI wa )Ia e
personally came before me this day and acknowledged that he is I-'{attl t p,-
of Vita IIO CI /)0S 1 r.- a 5 . and acknowledged.on behalf of lb • WO J j p_g_ SOS; j2., eA,,V:g
•
,the due execution of the foregoing instrument.
Witne�q {Mq�v pd official seal,this
c... s Le y of '`/o r, I .20 a 3
ittNOTARY PUBLIC
Wake County,NC Notary Frubli
c
My Commi gn p r ,2026 )(_ 07 d _ a ao.2(p .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
Re%.07/06