NCC241745_FRO Submitted_20240610

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
Q FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
ry WWITH 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: PINECREST RESIDENTIAL Extension: Yes or No
2. Road location of land-disturbing activity: WEST FOREST HILLS BOULEVARD
0821-32-86-9036,0821-32-73-4973,0821-32-78-7515,
Tax Map-Block-Parcel: 115415,115423,115424, P/O 115425, P/O 201750 PIN:P/O 0821-33-70-6241, P/O 0821-43-00-7990
3. Square footage of land to be disturbed or uncovered: 338,402 SF (7.77 AC)
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
WEST FOREST DEVELOPMENT LLC
Name
PO BOX 1202
Address
DURHAM NC 27702
City State Zip
704-340-0450 josh@«ambataproperty.com
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.
WEST FOREST DEVELOPMENT LLC
Name
PO BOX 1202
Street Address
DURHAM _ NC _ 27702
City State Zip
704-340-0450 [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.
201 E.Main St,5$h Floor,Durham,N.C.27701• [phone]• Fax[phone]
www.co.durham.nc.us/ceng

• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Name
Street Address
City State Zip
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.
Date Type or Print Name
Telephone Fax Title or Authority
Email Signature
*************************************************:**:**:******************************************,:*,:**:**:**:**:*************************
Business Applicant(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 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=
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE

■ Plan and conduct all land-disturbing activity so as to prevent ofT site sedimentation.
6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
Josh Hawn
Name
-
120 West Parrish St. , Ste B
Street Address
Durham NC 27702
City State Zip
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: (I) the owner of the Iand 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.
Date Type or Print Name
Telephone Fax Title or Authority
Email i lure
Business Applicant(Provide corporate resolution on signatory authority)
I, 5OLY 67 l� M C)YCCI. ,a Notary Public of the County of ( %V-11�N1
State of RQ)( Cja..3(���c� ,hereby certify that ,) SVI 17-k),
personally came before me this day and acknowledged that he is (,,._YARC li Y M Q 11•y
of IN tq F7 4- Vt 3hm,4 ind acknowledged,on behalf of W LSi c()Ye,* .QA/ J
the due execution of the foregoing instrument_ 0
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Witness my hand and official seal,this C.aa pTAR}�
day o Ju �' ,20
/ 1 M :IVI PI IBL\G
No r Public
sr,
My commission expires Q� 1 20),(r %, UN,�``
HI�"I/NI►flflIIIINe
Individual Applicant
1, ,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
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE