NCC241548_FRO Submitted_20240521

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
O FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
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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: Latta Park Extension: Yes or
2. Road location of land-disturbing activity: Guess Road and Latta Road
Tax Map-Block-Parcel: 232071, 182877, 182878 pIN: 0824-17-33-6727,0824-17-39-4345,0824-17-19-9214
3. Square footage of land to be disturbed or uncovered: 784,080 sf or 18 aC_
4. List below the landowner of record. Each landowner must complete Item S.
(If there are multiple owners,please list on a separate page):
KLLB AIV LLC
Name
6900 E Camelback Road,Suite 1090
Address
Scottsdale AZ 85251
City State Zip
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.
Tri Pointe Homes Holdings, Inc.
Name
5440 Wade Park Ave,Suite 400
Street Address
Raleigh NC 27607
City State Zip
919-300-4914 [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.uskeng

6. For business1 applicants,list below the North Carolina registered agent for the financially responsible entity:
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Name
5i-ksi o wades fk A-,re-n u . s u Q o
Street Address
IZeki.e.4) L 29-430 9-
Cityal'A Zip
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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.
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Date Type or Print Name
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Telephone Fax Tit a or Autho
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Email Signature
Business Applicant(Provide corporate resolution on signatory authority)
I, u S , C r-ad d y ,a Notary Public of the County of CLYe_
State of ,\-\Or\rh C,QrO\;r-)(t ,hereby certify that )r-;Sfi + i lard
personally came before me this day and acknowledged that he is D I r ee t..)(
of Lc c c De,/O\c p n- e )k and acknowledged,on behalf of r 1 1)0 rt\e o mes
,the due execution of the foregoing instrument.
Witness my hand and official seal,this I day of TUne, ,20 Q3
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aa�,ou�H 1eq
Notary Public 2 'y
My commission expires AucjuS\- ,20 arl , s NOTAF , <?&
PUBLIC
Individual Applicant `
I, ,a Notary Public of the County of 9�F +``��
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
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 by the person or entity listed in Item 5.
( •-24123 /414 Mail-
Dale Type or Print Name
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Telephone Fax Title or Authority
mail Signature
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Business Landowner(Provide corporate resolution on signatory authority)
1. fie.t"1 n i•?e C' 7 inn pp,,a Notary Public of the County of w A&4 Ga 1*
State of AVA?'VN4 _ ,hereby certify that •'MAN Malt
personally came before me this day and acknowledged that he is Atf 40041D C.(6
of ‘4441; AAv LL.G and acknowledged,on behalf of
,the due execution of the foregoing instrument.
— — SSTjtipp3iL gpyL"_1 412.1...1 irlal al.this 22 day of UN� 20 Z'i
Notary Public State of Arizona
Marlcopa Caunty
Jennifer Zinner -�
My Commission Expires 7/12/2026 Notary bh
NfV^C04l ii44614�x }3'4 t i'n e 2 2 . ,20 2 3
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
SE-03 Rcv.0710G