NCC231718_FRO Submitted_20230606

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
13E0 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
NC WITH LANDOWNER CONSENT FORM
�1881 t
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: Caliber Car Wash Extension: Yes or No
2. Road location of land-disturbing activity: 1311 W.NC Highway 54 Durham,NC
Tax Map-Block-Parcel: PIN: 0718-19-21-0167
3. Square footage of land to be disturbed or uncovered: 49,659
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
1311 NC 54,LLC
Name
8214 Westchester Drive, Suite 550
Address
Dallas TX 75225
City State Zip
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 fmancial 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.
Caliber Durham 54 OP CO,LLC
Name
3625 Cumberland Boulevard Suite 1150
Street Address
Atlanta GA 30339
City State Zip
404-483-7042 [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 fmancially 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,56 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:
William McCall
Name
38 Dan Owen Drive
Street Address
Hampstead NC 28443
City State Zip
404-483-7042 areddick(cr�,calibercarwash.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. 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.
04/5/2023 William McCall
Date Type or Print Name
404-483-7042 Au orized Officer
Telephone Fax Titl or Authori
[e-mail] /
Email ' nature
******************......***********************************************************************************************************
Business Applicant(Provide.€ J corporateorr resolution on signatory authority)
I,/e i7.✓Y! , a Notary Public of the County of
State of Gar.. ,hereby certify that /'�Clo//
personally came before me this day and acknowledged that he is I cyi '!•'�F"/ter'zee/ 01111/tioi
of Cc / �j/ ea, add acknowledged,on behalf of Cq� ``
1
,the due execution of the foregoing instrument. ^t.; NOj, ,' -
Witness my hand and official seal,this day of = • e r—
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Notary Public icO'Vj� *%2p2.
My commission expires F.p.L /4i ,200(4 . ����, G,O(*;0�
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.
Date Type or Print Name
3A — Sat► - 111A N C S.'‘‘.LLC
Telephone Fax Title or Au
Email Sig '..."""
Business Landowner(Provide
rate resolution on signatory authority)
I, 1—(0,G: T ,a Notary Public of the County of
State of—V*6s ,hereby certify that COY W1 .o Y>
personally came before me this day and acknowledged that he is M(,t r\
of i311 1-1c 54 , and acknowledged,on behalf of k"3 t NG 5 I y L.L.
,the due execution of the foregoing instrument.
Witness my hand and official seal,this day of L ,20 SJ
1rP�m�4 TRACI BODDIE
i%' S-.Notary Public,State of Texas T
Mycommis>bi"�' y' Comm.Expires 12-20-2026 20
otary Public
r„ Notary Iv 13 r8S3.06 '
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