NCC233647_FRO Submitted_20231211

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
.itrMt - 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 perrnittee 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: 1 ✓ L% Vd `-'"-
`'- -)---' '4,.=(--' 7..'"--7 71-` \ 'c'- Extension: Yes ,,l,r No
2. Road location of land-disturbing activity:\,... a'� L=I'.. ' ) y,-
Tax Map- Block- Parcel: PIN: (�/`i '"'j'-T—'3 :; C;,-'
3. Square footage of land to be disturbed or uncovered: 1 . ` ' ' /.�--
4. List below the landowner of record. Each landowner must complete Item S.
(If there are multiple owners, please list on a separate page): 7
Name
Address;'�
City State
ip
Z 15 —C,� 1 c-,-- — S Z---� :5- 1- Le_ n k.)- ) \ c,L,`? 1--\...T n"-1 ;.----, C-:r 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.
Name / d e-' /5ce i/ /lc:,-/i,.-7r
/' Y ,.. -a K C 7 /c. 11
Street Addr.;ss ,
/i"� ,-/J 4.4L 2. 7 7/
City _State _ Zip
Telephone Fax A Aec,e.,/,'n 3 ,� f i1.o -v, c,,a:,-•
Email
L/3 y- As the Financially Responsible Party, I consent to receiving notifications regarding this project via electronic
(lnnials) communication at / 7L4,.? o"c) 0-3 ,i /4 / c oT
([mail Address)
I agree to provide any updated email addresses as necessary to ensure consistent communication is maintained between myself
and Durham County Sedimentation and Erosion Control.
Electronic notifications may include Plans Review Comments, Approvals, Disapprovals,and/or enforcement actions including
Notices of Violation, Stop-Work Orders,and/or Civil Penalties.
201 E. Main St, 5th Floor, Durham, N.C. 27701 • [phone]• Fax[phone]
w,,w.co.durham.ne.usieeng

Name
Street Address
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. 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.
Date Type or Print Name
Telephone Fax Title or Authority
Email Signature
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Business Applicant LProvide corporate resolution on signatory authority)
h ,a Notary Public of the County of
State of , hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged,on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal,this day of 20
Notary Public
My commission expires ,20
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Individual Applicant
1. .a Notary Public of the County of_
State of , hereby certify that
personally appeared before me this date and tinder 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
Provide a Notarized Item 8 for each landowner listed in Item 4.

Date Type or Print Name
Tel pho Fax Title or Authorit
[;7
Email Signature
J};#;#*******YY***#****#}*}#****Y******YYY*# ....*Y2Y*Y#Y#YR;Y;#R#RtRYYYYR#YRA******►*****KY#RR}#R****************R##}}#}#F;####YY,,
Business Landowner(Provide corporate resolution on signatory authority)
I, , a Notary Public of the County of
State of , hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged,on behalf of
, the due execution of the foregoing instrument.
Witness my hand and official seal,this day of 20
Notary Public
My commission expires .20
*****Rt;*;#***;R}###*******Y****#*********************##R*Y*#Y*Y*Y***
Individual Landowner
, a Notary Public of the County of Dov14 -44.-.
State of A/C v-iff ( CZ e��.v � , hereby certify that C(4k C( Du—
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 Ver_rtvt 7E'i- ,20
Notary Pu
ESTHER KIM
My commission expires %Q /I c(-7/ 20 Notary Public
Durham Co., North Carolina
My Commission Expires Oct. 18,2026
The Sedimentation and Pollution Control Act(Act)and the Durham City-County ni led 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 2 I calendar days.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
SE-03
Rev.07;iI6