NCC242600_FRO Submitted_20240826

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
"C 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. Project name: SC Ai-Air.-Lev ';Z.'ESIPLE N Extension: Yes or No
2. Road location of land-disturbing activity: 6$ 98 ST.A.Q 'J 1LL Rr
Tax Map-Block-Parcel: Q ,1-{r'j - 3O PIN: psi-v7 3Q 9'i 9 9
3. Square footage of land to be disturbed or uncovered: Q 4 5580 S,V
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
G.N- c12-L'SS SMD NAT)SZ- iDA SG44-41c1Z.1�A�11
Name
O 3 L .N
Address
GNP-NI MC Z7512%
City State Zip
(984) 227- 4 2-7 c 1-k,N 12.Les . SC4-4 tz.t.AU @�► u..
Telephone Fax Email coM
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.
a IJ t Lt /*ig. Z I N C
Name
502. 12-tclsereG ,�V� surr . ZO►
Street Address -7 r�
IDlAg4}—,)4. � 1tC. 21 ! Oi
City State Zip
(fi 19) GG'7 -04014 RA.)lat..N/tz.E. Vte,tau 1LbS f lts1Q .
Telephone Fax Email co M
12.12. As the Financially Responsible Party,I consent to receiving notifications regarding this project via electronic
(Initials) communication at RU Bll R.. •EY',s @ t ,U)LD5EN5-c. •Cot-i
(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.us/ceng

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.
12.3 I2.0161 :e—eves
Date Type or Print Name
9 t91 6� 7 - OL-4r Oy- F1?-0 r c-r
Telephone Fax Title or Authori
_tz...0 EN 1?--ENIt% eU 11_.Ds-erIS _
Email Signature
Business Applicant(Provide corporate resolution on signatory authority)
I, l�r.fi 5•- I-toS ,a Notary Public of the County of I u 14-1
State of IN C_ ,hereby certify that 0 b 1 s
personally came before me this day and acknowledged that he is -os o 'Re 64 . c
of ?u i Ut S / Q and acknowledged,on behalf of Bu Icl —
,the due execution of the foregoing instrument.
Witness my hand and official seal,this 1 day of G ,20 23
. Nota Publi
My commission expires
/ 7 ,20 2 S ry
el
*********************************************************************************************************************************
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 KRYSTINE STER
Notary Public
North Carolina
Alamance County
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.
air 0 4 Q a pciz--s sc -rcr.t, A)
Date Type or Print Name
('t%' 121 - 2%42-1
Telephone Fax Title Authority
Email ignature
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
*********************************************************************************************************************************
Individual Landowner
I, K r IS h w
&.f ,a Notary Public of the County of
State of 10{/ ,hereby certify that C t`. 14-S SG k 14. IGv
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 2 M day of 0 L ,20 Z`3
Notary P blic
/
My commission expires Cr I 20
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 Rev.07/06
KRYNrEFOSTER
NotarySTI
North Carolina
Alamance County

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.
/C/02 ®a? 3 is%
Date Type or Print Name
kt4b old rizei
Telephone Fax Title or th &y
N4N.b1 .Sal p�cli;.t kle G--� ' P L. com
Email Signature
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
*********************************************************************************************************************************
44- Individual Landowner
I, Kr 5 hYLt.. 1705 kf ,a Notary Public of the County of Pt (.y✓i 0.4 c_
State of IU(_ ,hereby certify that /U« SGk cv k1
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 2 y day of G ,20 23
Notary ubli
My commission expires /7 20 Z
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 Rev.07/06
KRYSTINE FOSTER
Notary Public
North Carolina
Alamance County