NCC232110_FRO Submitted_20230714

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
O FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
•
:iv 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: Parking Lot Renovations Extension: Yes oi(No)
2. Road location of land-disturbing activity: 5325 Old Oxford Rd
Tax Map-Block- Parcel: 199497 PIN: 0845-58-93-3553
3. Square footage of land to be disturbed or uncovered: 188,538.60 SF (4.33 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):
m&zCK CIA1AP boNmE 4 L .
Name
5325 Old Oxford Road
Address
Durham North Carolina 27712
City State Zip
919.696.4157 919.884.4261 [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.
//EaGK SN42? >' 'c'ymE LLG
Name
5325 Old Oxford Road
Street Address
Durham NC 27712
City State Zip
919.696.4157 919.884.4261 sean.montaguePmerck.com
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.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
201 E. Main St,5th Floor,Durham,N.C.27701 •[phone]•Fax[phone]
www.co.durham.nc.us/ceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
CT Corporation
Name
150 Fayetteville Street Box 1011
Street Address
Raleigh North Carolina 27601
City State Zip
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: (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.
10 July 2023 Sean Montague
Date Type or Print Name
919.696.4157 919.884.4261 Director- Merck Global gineering Solutions
Telephone Fax Title or Authority
[e-mail]
Email STgnature�^
***********************************************************************************************************************************
Business Applicant(Provide corporate resolution on signatory authority)
Ocy\,a Notary Public of the County of l
State of•-r\.)j),� nc\.4.-,_, ,hereby certify that Sean Montague
personally came before me this day and acknowledged that he is Director- Merck Global Engineering Solutions
of Merck and acknowledged,on behalf of Merck
,the due execution of the foregoing instrument.
Witness my hand and official seal,this J . day of ,20 93
Mary Public
My commission expires , L ,20_
*********************************************************************************************************************************
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 ,•`NS .
•..L�
My commission expires 20 NOTARY
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE Q. PUBUC° j
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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.
10 July 2023 Sean Montague
Date Type or Print Name
919.696.4157 919.884.4261 Director- Global Engin erin Solutions
Telephone Fax r Authority
[e-mail] Qp/
Email ignature
Business Landowner(Provide corporate resolution on signatory authority)
1,. (..fit_ p v ,a Notary Public of the County of L5QjQ_,
State of Ont-Z ( cuic , v,c,hereby certify that Sean Montague
personally came before me this day and acknowledged that he is Director- Merck Global Engineering Solutions
of Merck and acknowledged,on behalf of Merck
,the due execution of the foregoing instrument.
Witness my hand and official seal,this /c 9' • day of ,20(9,3-N
now sJ
, ((�� Notary Public
My commission expires 'St , ,20 2-7
********************************************`**************************************************************************************
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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