NCC241068_FRO Submitted_20240410

JCN
Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EP 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: 3851 Hope Valley Road Extension: Yes or
2. Road location of land-disturbing activity: 3851 Hope Valley Road
Tax Map-Block-Parcel: 214595, 135113 PIN: 0719-77-22-5708,0719-77-17-0107
3. Square footage of land to be disturbed or uncovered:_705,968
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
Oldfourth LLC
Name
4711 Hope Valley Road. Ste. 110
Address
Durham NC 27707
City State Zip
919-619-5659 N/A
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.
Oldfourth, LLC
Name
4711 Hope Valley Road, ste 110
Street Address
Durham NC 27707
City State Zip
919-619-5659 na [e-mail]
Telephone Fax Email
5/0 As the Financially Responsible Party,I consent to receiving notifications regarding this project via electronic
(Initials) communication at [e-mail]
(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,5'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 fmancially responsible entity:
Bryson Powell
Name
11 Surrey Ln
Street Address
Durham NC 27707
City State Zip
919-619-5659 na [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: (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. �,
1 -bZcv -"L l ►�S ?ov3C.11
Date Type or Print Name
g I Cl-(p I -S(o Sri n Y1A AA.a a t.A/
Telephone " �p Fax Title or Authoo
VjitAs sn 6�ov3¢ ci�We.uo�MR GD.coM
EmailSign
Business Applicant JProvide corporate resolution on signatory authority)Nib /�
I, M tS ���I ,a Notary Public of the County of s �ri.�1�(1►1�
RVt State of tV i Q((v1 ,hereby certify that con i1JJJt
personally came before me this day and acknowledged that he is Ma,V),QfX
of 01 drtukci 1 L,C., and acknowledged,on behalf of ()\d tUft U1-
,the due' execution of the foregoing instrument.
Witness my hand and official seal,this 2tU,•,4 day of C,Ior ,20 27;
tiVa
Notary
My commission expires f)�11 ,20 25 . Misty N.Oa
1 Notary Public•North Carolina
********************************************************************************* sae****Graf tAhlEa******* *****************
My CemmhBon Expires APB 8,2025
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.
10-26-23 Oldfourth, LLC
Date Type or Print Name
919-619-5659 na Manager
Telephone Fax Title or Authority
[e-mail]
Email S'
Business� n Landowner((Provide corporate resolution on signatory authorityl
MIN
I \ ()EN ,a Notary Public of the County of tt�� ( cCUR
State of a , c o i� \O ,hereby certify that Fr l-Owei1
iacknowledged that he is o,,�
personally came before me this day and _ lM 1 Ne.,(
of (01611,NA ttr., and acknowledged,on behalf of D1(n{U i-\1
,the due execution of the foregoing instrument.
Witness my hand and official seal,this 2Ui'' day of 1,p 00/ ,20 23
Not' ary Publ
My commission expires ' 1``'X\ % ,20 26 . Misty N.Notary Public-North
�}Cyarolina
,�
My CaTmsu4.n 8ipims April S,2025
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