NCC242450_FRO Submitted_20240814

JCN
Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
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: RAL_2 _Extension: Yes or No
2. Road location of land-disturbing activity: 6768 Stagville Road,Durham NC
Tax Map-Block-Parcel: CAMERON GROUND/LT#B2 PL000190-000045 PIN: 0846299164
3. Square footage of land to be disturbed or uncovered:_ 99,195 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):
Tyler and Lauren Coulombe
Name
503 Silver Fox Circle
Address
Hillsborough NC 27278
City State Zip
919-451-1328 [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.
Tyler and Lauren Coulombe
Name
503 Silver Fox Circle
Street Address
Hillsborough NC 27278
City State Zip
919-451-1328 [e-mail]
Telephone Fax Email
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,5ih Floor,Durham,N.C.27701 •[phone]•Fax[phone]
www.co.durham.nc.us/ceng

JCN
Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
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: RAL_.2 ____Extension: Yes or No
2. Road location of land-disturbing activity: 6768 Stagville Road,_Durham NC
Tax Map-Block-Parcel: CAMERON GROUND/LT#B2 PL000I 90-00004 PIN: 0846299164
3. Square footage of land to be disturbed or uncovered: 99,195 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):
Tyler and Lauren Coulombe
Name
503 Silver Fox Circle
Address
_Hillsborough NC 27278
City State Zip
919-451-1328 [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.
Tyler and Lauren Coulombe
Name
503 Silver Fox Circle
Street Address
Hillsborough NC 27278
City State Zip
919-451-1328 _ _ [e-mail],___�
Telephone Fax Email
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.uskeng

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.
5-14-24 Caruso Homes On Your Lot
Date Type or Print Name
2408863229 Applicant/General Contractor
Telephone Fax Title or Authority
[e-mail]
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
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.
gC"/ Tyler&Lauren Coulombe
Date Type or Print Name
919-451-1328 Owner/Financially Responsible Party
Telephone Fax Title thority
tc1b2023 ail.com
Email Si ature
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
IndiivvidualIiandownee (. [� I _
I, V'0 C Y/ e, V r.g 3 t,a Notary Public of the County of_o A 1 `�
State of N V V ("3 U I ( fl N ,hereby certify that T\. f 'l, Imo- 0 0 (AI V Y 1.
personally appeared before me this date and under oath acknowledged that theabove form was executed by them.
Witness my hand and official seal,this ,2 0 "1 h day of 1 "/ 0 ,20 /Li
jívJ 0 ` a �L�--
My commission expires v 4 I [2_ 20 Z 9(
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 laulganifilling activity so as to prevent off-site sedimentation.
SE-03 ` 0 Rev.07/06
-A
Ortb to
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wig 1111lo"

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.
2012_0 2 9 Tyler&Lauren Coulombe
Date Type or Print Name
919-451-1328 Owner/Financially Responsible Party
Telephone Fax Titl or Authority
[e-mail]
Email Signature
Business Landowner rovide corporate� � resolution on signatory authority) �U
I, C 0 I I 1 a Notary Public of the County of
State of lit 1 Jerreby 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
*****************i***********i**********ii*i*******t***tit*t*tit*************************************************i**it******t****
Individual Landowner I, C I O 1 ��/�I ,a Notary Public of the County of _0 12' k IN &F State of N (- ("1 (2O I l nJ ,hereby certify that L V 1 ( ) c U IA I ( pY
` i✓ J
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 Z 0 ' t 1 day of ,20 2
,) ad 0
Notary Public
My commission expires 0 —i 1 1 2 20 2 0
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 ,,,,%tt Sd3d,'',�% Rev.07/06
4114.
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0
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