NCC233782_FRO Submitted_20231221

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COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
MC 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: The Advantage Extension: Yes or No
2. Road location of land-disturbing activity: 1604 Olive Branch Road, Durham
Tax Map-Block-Parcel: 194245 PIN: 0769693797
3. Square footage of land to be disturbed or uncovered: 435,600 sf(10.00 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):
LTB Developers, LLC
Name
5310 NC Highway 55, Suite 101
Address
Durham NC 27713
City State Zip
[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.
LTB Developers, LLC
Name
5310 NC Highway 55, Suite 101
Street Address
Durham NC 27713
City State Zip
'1q'5L1q.019 I [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.
• 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:
Bruce Knott
Name
5310 NC Highway 55, Suite 101
Street Address
Durham NC 27713
City State Zip
[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: (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.
812023 Bruce Knott of LTB Developers, LLC
Date Type r Print Name
qlR-9y4- 0ILI a
Telephone Fax Tit r Au
[e-mail] k •
Email Signature
Business Applicant(Provide corporate resolution on signatory authority)
I, tY'�c`G�• Vo A"ic.ait'000,a Notary Public of the County of .lx rh �
State of 'Veet4m 04/-13(Inek._ ,hereby certify that 3rtz. W . K('‘Ott
personally came before me this day and acknowledged that he is M114..5¢X
of LT Qj rQ.tope cs I LL ... and acknowledged,on behalf of L I(3 1042„rp.1p perS
,the due execution of the foregoing instrument.
Witness my hand and official seal,this anti-h) day of - , ,20 a3
11//� Notary Public
My commission expires A/ow VN.OP.Y' 4 ,204af .
- - Durham Count North Carolina
y
Deanne P. Fabricatore
Individual Applicant My Commission Expires 11/04/2024
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 70
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 b the erson or entity listed in Item 5.
g/22o2_3� Bruce Knott of LTB Developers, LLC
Date q
IV111- 9414-01141Type or Print Name
Telephone Fax rtl- or Au ri
[e-mail] pi -iti ,
Email S gnature
....*....*:*«...**************.,*************.***.************ .**********************************.*******$*************************
Business Landowner(Provide corporate resolution on signatory authority)
I, -..► urine,-P. co_brtc .,cure..-a Notary Public of the County of &t x.Awn,v
State of K6rilh Caraftnd, ,hereby certify that Tr tAte 14. ttivrtt
personally came before me this day and acknowledged that he is Rajiv,oe r
of LTo lealel C.)✓�el'S� LLC. and acknowledged,on behalf of Li.$ e-lOpecs i LLB.
,the due execution of the foregoing instrument.
Witness my hand and official seal,this ,l$4I day of ArtittL.STA ,20.2.3
Notary Public
My commission expires AiiIVey ►tIQX` if ,2044
;J°�`�5^ �1� Durham County,North Carolina
********.***********.****************.*..*******************************************- %� Notary Public
� ° _ eanne*I . a `raetor*�*.*k..
Individual Landowner s` ,,+` My Commission Expires 11/04/2024
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