NCC240175_FRO Submitted_20240122

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
Q FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH 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: l.i aty i-on 1-6,14 L ah Extension: Yes or No
2. Road location of land-disturbing activity: 1 )2-0 E —7 1 Z 2 Gut S S Rd . 1--Us bcr 4 U° C-
Tax Map-Block-Parcel: PIN:0 UI(9-67—74 -17 O i 51-1 3119
3. Square footage of land to be disturbed or uncovered: ("+ , 501 c, , ..(# . C 0. 55 Ct(r're
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
(',rh 14- 140 me r 1, e
Name
S000 C( iN
Address
01011), VI I it 3-1 Tr()
City State Zip
°I101-17 2 —5013 9101-.7 7z ectrievit + ivmpk , A &)CIG‘' 1114Na1'le9
Telephone Fax Email COY*"
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.
CA 14 140 nTe51 C Name
00t) J0 fr d .
Str et Address
rv1cArvv; 1 pe TA) � ��1 I
Cf State Zip
1°i— 71 cL) +`3 °ti9�1�2- 4512 cJUfItYle . I1, D\L @ GcAy{,t,el homes
Telephone ti
Fax Email COY
As the Financially Responsible Party,I consent to rec 'wing notifications regarding this project via electronic
(Initials) communication at Clc-rievl (vwt91(./ kV C[c4,y f3A140 v`lP S . (0,M
(Email 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,5te 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:
C i (1Of 0-r0r-1' ©bA c y S Name I
I 0 Mile LQ14p Ct
StreetAkQl �
se ) VI fVC 77b !1 S
City � CJ State 7ip
S 0 U Ain.4-ech,N1 a 6) VO 11-6(5 hi wee. co ik\
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.
I o /acJz Da ri it)e Liwpk;4 , Ctas / kos
D1,)C1-T11 -So,3 e Type or GM
Name
Telephne Fax r)e'At, ( v i Sp k Q CA D14 b4lno4►e S, CO r'l ..tle or Auth ty
Email S ure
1 Business Applicant(Provide corporate resolution on signatory authority) , ' )�(L/�
I, L (5 A. /4' IA)LIS( CI ?a..Cy ,a Notary Public of the County of t/+� -e
N State of c _ ,hereby certify that -Da ( l e _____L.t IM1 !C( h
personally came before
m�ethisk
day and acknowledged that he is (Le '&1. V' CL.i,...� '1
``o.f I L Lb.a-L(4 v ITS�""�` and acknowledged,on behalf of C 4 (� lyr�S J- n G
` P�' YS c e„, J ,the due execution of the foregoing instrument
�V,i�n�esss�my ha nd official seal,this day of L/C 20
NOTARY
�• i,,,,, 2:-(' --- ti).2)Yezi ez--e—c-
No
— Public Q J i
oxcommi iq xpires
N ( C� , SS 20 2
•%%i%! C n��' \`
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
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
9 H-17 2.- Co t 3 N/P- CstAA
Telephone Fax itle or Au ority
t- P
Email � —�—�& c � �I �,,gnature
Business Landowner(Provide corporate resolution on signatory authority)
I, 1 1 S/-�- A L0I S)141.e. (ya Notary Public of the County of VA
State of f " C- ,hereby certify that 'Da 1-VII,e ✓v,P)Ct Pi
v
personally came before me this day and acknowledged that he is O''vim 6...-Q U AC4.,,tnc..c.e,t
``\`a��'PtP'+ i,,�� l^ S and acknowledged,on behalf of CAA 1 (`T cv�S I h G
�fY<2.; - ,the due execution of the foregoing instrument.
OA 7 _
�Earan official seal,this �� day of �� 20 2
ti A�`- . C; y�c�
%ram✓s . „ti.
�r
d, @1n expires 7 — (6, 20 Notary P blic
*********************************************************************************************************************************
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
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.
SE-03 Rev.07/06