NCC241254_FRO Submitted_20240423

DURHAM JCN
C O U N T Y 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: Gilliam-Williams Extension: Yes or No
2. Road location of land-disturbing activity: 11 0 Kilt Way Durham NC 27712
Tax Map-Block-Parcel: 83678 pIN:0816513410
3. Square footage of land to be disturbed or uncovered: 153,309 sf
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
John Gilliam&Mary Williams
Name
6 Kerr Ct.
Address NC 27713
Durham
City State Zip
703-881-1260 [e-mail] [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.
Jason Radford-Radford Building Company,LLC.
Name
510 Chutney Dr
Street Address
Durham NC 27712
City State Zip
919-257-1925 [e-mail]
Telephone Fax Emai I
JR 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,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:
Jason Radford-Radford Building Company,LLC.
Name
5103 Chutney Dr.
Street Address
Durham NC 27712
City State Zip
919-257-1925 jason®radfordbuildingcompany.com
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.
3-19-24 Jason Radford
Date Type or Pr' t Name
919-257-1925 Owner-C actor
Telephone Fax Title uthori
jason©radfordbuildingcompany.com
Email Si ture -
***********************************************************************************************************************************
Business Applicant(Provide corporate resolution on signatory authority) �` L.L.�%%Illliiii�
I,VO.�riS$ ..9. l7 MDf ND ( ,a Notary Public of the County of �(�,41�Q, .N S ,,i'
State of N ,hereby certify that S an (Oa-6 rd ��,
_ 'R% 01,1.
Q't� •
personally came before me this day and acknowledged that he is OW()Cc —cj r 'ta - =Q / 2 Z
of t'\ V \` Q. and acknowledged,on behalf of Ow nobs--G r'. ' , .40Z.'
,the due execution of the foregoing instrument. C'�I°/o,,�% wP;�`%
Witness my hand and official seal,this 2� da of �urZJr\ ,20 Z� 11111
N ary Public
My commission expires \_-6/\\31q 11 ,20 Z� .
ilks-'()%X"{)
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.
3-19-24 John Gilliam & Mary Williams
Date Type or Print Name
703-881-1260 Property Owner
Telephone Fax Title or Authority
[e-mail] [e-mail]
Email Signature /16Agie(
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
Individual Landowner , I v
I, 1.-11,Q 'w �i ,a Notary Public of the County of w k1``e-
State of 1v `f\A\ C�r l�\ �� ,hereby certify that ,\()sr., G •``'s <1 4,03v`1 1\•��1�^S
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witr ess my hand siairsiefiseal,this_ � day of « _ ,20 21A,
NOTARY PUBLIC
Wake County,North Carolina
My Commission Expires October 30,2028 Notary P is
My commission expires 06-0 , �0 20 22.„
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