NCC241787_FRO Submitted_20240612

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
O 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. Projectname: 3824 Angier Avenue NOV
2. Road location of land-disturbing activity: 3824 Angier Avenue Durham,NC 27703
Tax Map-Block-Parcel: 163023 PIN: 0840-50-25-8413
3. Square footage of land to be disturbed or uncovered: 199966.54 sqft
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
Raunel Benitez
Name
3917 Devonwood Road
Address
Hillsborough NC 27278
P
919-225-4315 State Zi J (_I 1�1 D n U�E L p1�1 Gn An c.C.o4,
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.
( u rl1t. Kt4z. .l(t-
Name
3 C11 •txu o.a‘.roo o 'Q t)
Street Address
NluhYkliaX..14 )JC- ��2-'34.
City State Zip
9l9 0-6 Lit/6 4�1ZAvNELT�j� GMR(G Cpw+
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,5th Floor,Durham,N.C.27701•[phone]•Fax[phone]
www.co.durha®.oc.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 fmancially responsible entity:
LAv r) t, t-r4Z a(Z-
Name
3`tt 3}¢,uo,-1 woo°
Street Address
14I1-1/2 o N/C
City State Zip
qlq zi' 4t 3I'S 1-1P- + t'% r11111L. t..oW1
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.
$-(o- ur�Ru, St-
Date Type or Print Name
M tq 224 411. pxrlolttzi6,0 iND t ipuivc.
Telephone t� Fax File Authority
RV-Cly 14C-C ha &thq 1 l_-Coon ����'
Email Signature
Business Apnlicant(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, i.vki e,, t,SiVctl0. ,a Notary Public of the County of t)u V WW1
State of N v wLvl C xv(l"9 ,hereby certify that 4t.t L\ &mttt? 112..
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 L-P day of/tom„ S
_ Public ,g F�
{��
My commission expires I V &t 1 20 '2 NOTAAV
LAND DISTURBING PERMITS ARE NON-TRANSFERABLE 4 PUMA
%.4m F•

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.
—Z07-3 tL i L iS g
Date Type or Print Name
`ticl 224 4316 qjv ovizap `OD(vrn (-
Telephone Fax Ti e or u on
NG.K rt-/St- g rhAlr., c
Email rgnature
Business Landowner PProvide 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, b41(` - Estrella ,a Notary Public of the County of D M kaLW1
State of 1 V tN 1t ,hereby certify that V Ol,l,U&1A
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 GQ day of ,20 Z7-
My commission expires 4M1,0/+ 20
SE 03 G�1` A F�� Rev.07106
JNkOTAR Y
).
PUMA c,