NCC242573_FRO Submitted_20240830

JCN
DURHAM
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
II
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: Wabash Parcels Extension: Yes or No
Wabash Street and Ridgeway Avenue
2. Road location of land-disturbing activity:
Tax Map-Block-Parcel: 117793, 117801, 117802 PIN:0830-27-8950, 0830-28-7207, 0830-28-8247
3. Square footage of land to be disturbed or uncovered: 285,998 SF (6.57 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):
Habitat for Humanity of Durham, INC.
Name
PO Box 11860
Address
Durham NC 27703
City State Zip
919-451-7538 [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.
Habitat for Humanity of Durham, INC.
Name
PO Box 11860
Street Address Durham NC 27703
City State Zip
919-451-7538 [e-mail]
T 1 i one Fax Email
' ,<_ As the Financially Responsible Party,I 3 ent to r ceivinnotificati ns rearding this project via electronic
nt,ais) communication at , �?yi-16,(0D . ,
(Email A.dress)
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,5'Floor,Durham,N.C. 27701 •[phone]•Fax[phone]
www.co.durh am.nc.0 s/ceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
ila" 16 uin4•41v` 7 ' 71//rhc(.61
Name
PO Box 11860
treet Address urham NC 27703
CityState Zip
919-451-7538 ---", r r- le - 1 h j , 4v)
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.
fr k ~joy 0i
C lc-1)60,172- Osi& xios
(41. Type orPrint Name
_ aephone Fax ` 't e or Authori` ithiki4 .
Email ignature
Business Applicant(Provide corporate resolution on signatory authority)
I, (1/0 Ze- (6/ifi iS ,a Notary Public of thee County of W(Ce--K`
State of krill Cro4/i it&.. ,hereby certify that r!z )& c� Vuv
personally came before me this day and acknowledged that he is a©
of IIabst- 6 1-iunlas tiviL,fhow, and acknowledged,on behalf of HG /l? ' ,r tei'ha V1.4
,the due execution of the foregoing instrument.
Witness my hand and official seal,this /S day of A--t ,20 -Z
Notary Public
My commission expires /(,�41 3/ gl- ,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

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.
1/ 02( 1
Da Ty eor Pant Name
� � � ..
Tee one Fax Ti or Authority
Email / S'gnature
***********************************************************************************************************************************
Business Landowner(Provide corporate resolution on signatory authority)
I, l'G►2n �Or<I i'r6 ,a Notary Public of the County of vo
State of NtrT ettrt/lncc, ,hereby certify that 1fa04d TOt1ruu'
personally came before me this day and acknowledged that he is
of 1-ktbda 6't1CgYl f 101410v4'1 and acknowledged,on behalf of 1I / 0- 4,2nt& PTV +yt
,the due execution of the foregoing instrument.
Witness my hand and official seal, this /5—i-k day of M ,20 �4"
ekm,,,,2. dabs,
� z St.-
Public
My commission expires `Cl c5t ,20 L9 .
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
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