NCC241488_FRO Submitted_20240516

Financial Responsibility Ownership
1 ENGINEERING
(Sedimentation Pollution Control Act) SERVICES
One Exchange Glaze.L.it_304
1
Raleigh,NC 278M
TAis section to be cot?Dietedlby City o'Rarei9n start
Submittal Date Effective Date
Transaction Number Permit Number LD-
The remaining sectIrs to. c.rnp,eted by the rippt am
SECTION 1: GENERAL INFORMATION&INSTRUCTIONS 1
-
This form is required to be completed, notarized and submitted with all Land Disturbing Permit applications The
informaton provided herein becomes an enforceable part of the approved Erosion and Sediment Control Plan
and the Land Disturbing Permit listed above Non-compliance may result in the assessment of civil penalties
and could potential')y affect all permits. inspections andlor Certificates of Occupancy for this Project. Should any
of the information on this form change, a revised, executed form shall be submitted within thirty (30)days, said
submission shall include a copy of any documents recorded with the Register of Deeds.
The effective date of this form shall be the effective date as designated above by the City of Raleigh No rights
and liabilities associated with any designation shall incur until the effective date or the effective date of transfer
to any subsequent Party Upon any delegation of an Applicant/Permittee or Financially Responsible Party, the
Owner shall continue to receive notice at the address provided.
A permit may not be transferred to a residential Home Owner's Association as the ApplicantiPermlttee or
Financially Responsible Party. until the issued Land Disturbing Permit for this project is administratively closed
by the Stormwater Management Division,
Raleigh City Code§14-1011 sets forth that tt shall be unlawful and a violation of this code for any person to give
false information or misrepresentations in any application or permit required by this code Failure to provide full
disclosure of the requested information may be grounds for denial or revocation of a Land Disturbing Permit.
Please complete all sections below. Type or print and if information on the form is not applicable, place NIA in
the blank. All pages of this form must be completed and submitted or the form will be rejected and returned.
The property owner must initial each page of the form prior to submittal.
SECTION 2: PROJECT INFORMATION
PROJECT NAME Doral Academy Modular Building Expansion
PERMITTED PHASE(S)
PROJECI.ADDRESS 7000 Destiny Drive Raleigh, NC 27604
WAKE COuN Y PARCEL ID 1735866398
NUMBER(S)
ANTICIPATED DATE c. July 2023
PROJECT INITIATION y
EXPECTED DURATION OF 3 Months
PROJECT
ACREAGE OF LAND TO BE 0 94
DISTURBED
PROPER IN tits NFR'z INmAI ti Sr,:rn:44Ti:r lulxctrnnc Fnrm 112
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T SECTION 3: PROPERTY OWNER INFORMATION 1
School Development Destiny LLC
PROPERTY OWNER OF RECORD
6457 Sunset Drive 305-665-6732
MAILING ADDRESS(NO P 0 BOX) TELEPHONE NUMBER FAX NUMBER
Miami, FL, 33143 [e-mail]
CITY,STATE,ZIP E-MAIL ADDRESS
The undersigned acknowledges that he is the Owner, or holds the Owner's power of attorney, of the property
which is the subject of this application, and further states that the permitted land-disturbing activities are
authorized to be conducted on the subject property with the full knowledge. permission and consent of the
Owner.
The undersigned acknowledges that he is the Property Owner for permit implementation, compliance and
enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance. Article 9.4. The
Owner of the property upon which the land-disturbing actvity is to be undertaken states and affirms that he has
read and understands the statements and disclosures made in this form and that the information disclosed
herein is true and correct to the best of his knowledge and belief
This form must be signed by the Owner of the property or by a person with authority to execute instruments, if
the Owner is not an individual,
r ,20 2�1
This,the �.�- daV of Nlc�y
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PROPERTY O'J�JNEF SIGNATURE TITLE
IN WITNESS WHEREOF,the undersigned Notary Public has hereunto set his hand and seal.this
1 nn
day of 1'I 11 :20 /11
Notary Public print name) Notary Public' igriature
My Commission Expires. I}-51\ab
Notary Public Title]Position
TW..NKY R.PEREZ
iis .".:\ MY COMMISSION$NH't33754
4%.' e.�-�: —E<PIRES:JameySI,2028
d�hv Heart. .,aa tr'v;Lera 16- (SEAL)
PROPERTY OW:NkIt'S txtnAI57 I .±(arxrwnrer InsAvunm Form 11:
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SECTION 4: OWNER'S APPOINTED AGENT INFORMATION -
The Owner of the property upon which land-disturbing actvities will be undertaken is required to either reside in
or appoint an agent for service with business and residence addresses within Wake County. North Carolina
Section 4 must be completed if the Property Owner listed in Section 3 does not reside in Wake County,
North Carolina and is optional for all others.
The Owner of the subject property hereby appoints the following person as an agent to receive service of any
notice, process, or pleading in any action or legal proceeding arising out of any matter relating to Unified
Development Ordinance, Article 9.4_ The Owner agrees that any notice process. or pleading may be served by
and through the undersigned appointed agent and such service shall have the same force and effect as if
service was accomplished upon the Owner.
re l ( Vl!ait;0. e l 1, Registered Agent
NAME 10 TITLE
Corporation Service Company 800.927.9800
COMPANY, IF APPLICABLE TELEPHONE NUMBER
2626 Glenwood Avenue, Suite 550
STREET ADDRESS I.NO P.O. BOX) FAX NUMBER
Raleigh, NC 27608 Cb �
_ Y1t I c' c 0—�( )\\ . C-
CITY. STATE, ZIP E-MAIL ADDRESS
The undersigned acknowledges that he/she Is the Owner's appointed agent.
This, the day of, Ka� .20 a3 .
Ss`is ue, P key-y
APPOINTE AGENT SIGNATURE TITLE
IN WITNESS WHEREOF,the undersigned Notaryl Public has hereunto set hisiher hand and seal_this
r7Jr6 day of— �`l 20 �c3
�o l �t Se 4�-1--
Notary Public(print name) 1 1 I Notary Public Signature
My Commission Expires. 9/3/c�'"1 __._,
Notary Public Title/Position
OFFICIAL SEAL
LAUREL BIETSCH
gKiT\RY PUBLIC. STATE OF ILLINOIS
MY COMMISSION EXPIRES 09.0-2024
PROI[R IN OWNER'S INI CIA'S: 404 .ii r'ester hupei tloru Form Ili
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fJ SECTION 5: FINANCIALLY RESPONSIBLE PARTY INFORMATION J
The Owner of the subject property authorizes the following person or firm as the Financially Responsible Party
for this Land Disturbing Permit The Financial Responsible Party shall receive service of any notice, process,
civil assessment or pleading in any action or legal proceeding ans,ng out of any matter relating to the Land
Distur 'ng Permit' sued under this permit application and Unified Development Ordinance Article 9 4.
MIli n K
FINANCIALLY RESPONSIBLE PARTY TITLE
School Development Destiny LLC 305-525-5923
COMPANY, IF APPLICABLE TELEPHONE NUMBER
6457 Sunset Drive
STREET ADDRESS iNO P O BOX) FAX NUMBER
Miami, FL 33143 [e-mail]
CITY. STATE, ZIP E-MAIL ADDRESS
The undersigned acknowledges that he is the Financially Responsible Party for permit implementation.
compliance and enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance,
Article 9.4 He has read and understands the statements and disclosures made in this form, that the information
disclosed herein is true and correct to the best cf his knowledge and belief
This form must be signed by the person or firm financially responsible for the land developing activity or other
person with authority to execute instruments far the financially responsible party, if not an individual
This,t $ ilida of M 1 . 20 13
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FINANCIALLY RESP NSIBLE PARTY SIGNATURE TITLE
i
IN WITNESS WHEREOF,the undersigned Notary Public has hereunto set his hand and seal this
22 day of Mr .20 23
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Notary Public(paint name} Notary • Sign e.
My Commission Expires: t)fi . )' Lam"
Notary Public Title/Position
---
hi `- bay CUM!WON 'H 183754
rY R.PEREZ
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i - , .,; EXPIRES:J;,ns;ary 31,2024
(SEAL)
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05.23.16

I SECTION 6: APPUCA PERMITTEE
The owner of the subject property authorizes the following person or firm as the ApplicanVPermittee to receive
service of any notice, process, civil assessment or pleading in any action or legal proceeding arising out of any
matter relating to the land Disturbing Permit issued under this permit application and Raleigh Unified
Development Ordmance, Article 9.4. The App!icanVPermittee designated below 's the person responsible for
implementatton of permtt conditions and violation under Article 9.4 of the Raleigh Unified Development
Ordinance.
The Applicant/Permittee may be the landowner cr another party who acknowledges that he s the Contractor
responsible for completion of the project as approved.
Richard S. Losee President
APPLICANT/PERMITTEE TITLE
LAI Construction Management, Inc. [phone]
COMPANY, IF APPLICABLE TELEPHONE NUMBER
9911 Corkscrew Road
STREET ADDRESS (NO P.O. BOX) FAX NUMBER
Estero. FL, 33928 rlosee [e-mail]
CITY, STATE, ZP E-MAIL ADDRESS
The undersigned acknowledges that he s the Applicant/Perm,ttee for permit implementation, compliance and
enforcement resulting under the Land Disturbing Permit listed above and Unified Development Ordinance,
Article 9.4. He has read and understands the statements and disclosures made h this form and that the
information disclosed herein s true and correct to the best of his knowledge and belief.
This form must be signed by the person or firm responsible for the permit or tv a person with authority to
execute instruments for the Applicant/Pemilttee, if not an individual.
..i
This, the i,e311i day of__L( ___ , 2023
A' . 1 r r rCtee1, —
APPL Iiiipr RMITTEE SIGNATURE TITLE
N WITNESS WHEREOF, the undersigned Notary Public has nto set hts hand and seal. this
p,J ' dayof r__ __ .20 Z.3
, P-ratc J 1 i(t)
.Z.- ,
otary Public (print ame) Notary Pu c ignature
My Commission Expires: ( [2.tZ_( 1 u o
Notary Public TUe/Po ition
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1 .;•�*pr°e'.. ANNETTE M.CARRASQUILLO
r°/��` Notary Public•State of Florida 1
"a yc`: Commission<FIN 152345
'�''�o ' My Comm.Expires Jul 15,2025
(SEAL) I 3or.cec through Natioral Notary Assn. ;
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