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Home My WebLink AboutNCC243018_FRO Submitted_20240930 Financial'Responsibility Ownership A '. ' ENGINEERING (Sedimentation Pollution Control Act) ``'_""'_'' SERVICES One Exchange Plaza,Suite 304 Raleigh,NC 27601 This section to be completed by City of Raleigh staff Submittal Date Effective Date Transaction Number Permit Number LD- The remaining sections to be completed by the Applicant SECTION 1: GENERAL INFORMATION & INSTRUCTIONS This form is required to be completed, notarized and submitted with all Land Disturbing Permit applications. The information provided herein becomes an enforceable part of the approved Erosion and Sediment Control Plan and the Land Disturbing Permit listed above. Non-compliance may result in the assessment of civil penalties and could potentially affect all permits, inspections and/or Certificates of Occupancy for this Project. Should any of the information on this form change, a revised, executed form shall be submitted within thirty (30) days, said submission shall include a copy of any documents recorded with the Register of Deeds. The effective date of this form shall be the effective date as designated above by the City of Raleigh. No rights and liabilities associated with any designation shall incur until the effective date, or the effective date of transfer to any subsequent Party. Upon any delegation of an Applicant/Permittee or Financially Responsible Party, the Owner shall continue to receive notice at the address provided. A permit may not be transferred to a residential Home Owner's Association as the Applicant/Permittee or Financially Responsible Party, until the issued Land Disturbing Permit for this project is administratively closed by the Stormwater Management Division. Raleigh City Code §14-1011 sets forth that it shall be unlawful and a violation of this code for any person to give false information or misrepresentations in any application or permit required by this code. Failure to provide full disclosure of the requested information may be grounds for denial or revocation of a Land Disturbing Permit. Please complete all sections below. Type or print and, if information on the form is not applicable, place N/A in the blank. All pages of this form must be completed and submitted or the form will be rejected and returned. The property owner must initial each page of the form prior to submittal. SECTION 2: PROJECT INFORMATION PROJECT NAME Alexander YMCA Expansion PERMITTED PHASE(S) One (1 ) PROJECT ADDRESS 207 Cox Avenue WAKE COUNTY PARCEL ID NUMBER(S) 1704009101, 1703097947,1703097933,1703097834, 1703098932,1703098993, 1703099945,1703190906 ANTICIPATEDDATE OF August ust 2024 PROJECTINITIATION /"� C� PROJECT EXPECTED DURATION OF 24 Months ACREAGE OF LAND TO BE 0 Acres DISTURBED PROPERTY OWNER'S INITIALS: Stormwater Inspections Form 112 08.01.16 Page 1 of 5 SECTION 3: PROPERTY OWNER INFORMATION Young Men's Christian Association of the Triangle Area, Inc. PROPERTY OWNER OF RECORD 801 CORPORATE CENTER DR STE 200 919-719-9622 MAILING ADDRESS (NO P.O. BOX) TELEPHONE NUMBER FAX NUMBER Raleigh, NC 27607 Brian.Keel@YMCATriangle.org CITY, STATE, ZIP E-MAIL ADDRESS The undersigned acknowledges that he is the Owner, or holds the Owner's power of attorney, of the property which is the subject of this application, and further states that the permitted land-disturbing activities are authorized to be conducted on the subject property with the full knowledge, permission and consent of the Owner. The undersigned acknowledges that he is the Property Owner for permit implementation, compliance and enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance, Article 9.4. The Owner of the property upon which the land-disturbing activity is to be undertaken states and affirms that he has read and understands the statements and disclosures made in this form and that the information disclosed herein is true and correct to the best of his knowledge and belief. This form must be signed by the Owner of the property or by a person with authority to execute instruments, if the Owner is not an individual. • This, the 15.1—` day of M P tr. I-t , 20 23 . 1,2 ERTY GIVAER SIGNATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this (6 day of ifa/ 4 , 20n2 "J CithriS Nka,riche(NeD ary Pubic(print name) Notary P9lic Sig ture My Commission Expires: la-a 1��P �r0 (V b / aiL Notar,Public Title cVPosition 01.14 A Ry tip;, Q k.CATL) 0 COMMISSION EXPIRES 0 2/22/2028 % PUBLIC .�`��c PROPERTY OWNER'S INITIALS: *, tJN\NO Storm water Inspections Form 112 08.23.16 Page 2 of 5 SECTION 4: OWNER'S APPOINTED AGENT INFORMATION The Owner of the property upon which land-disturbing activities will be undertaken is required to either reside in or appoint an agent for service with business and residence addresses within Wake County, North Carolina. Section 4 must be completed if the Property Owner listed in Section 3 does not reside in Wake County, North Carolina and is optional for all others. The Owner of the subject property hereby appoints the following person as an agent to receive service of any notice, process, or pleading in any action or legal proceeding arising out of any matter relating to Unified Development Ordinance, Article 9.4. The Owner agrees that any notice, process, or pleading may be served by and through the undersigned appointed agent and such service shall have the same force and effect as if service was accomplished upon the Owner. Not Applicable NAME TITLE COMPANY, IF APPLICABLE TELEPHONE NUMBER STREET ADDRESS (NO P.O. BOX) FAX NUMBER CITY, STATE, ZIP E-MAIL ADDRESS The undersigned acknowledges that he/she is the Owner's appointed agent. This, the day of , 20 APPOINTED AGENT SIGNATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his/her hand and seal, this day of , 20 Notary Public(print name) Notary Public Signature My Commission Expires: Notary Public Title/Position (SEAL) PROPERTY OWNER'S INITIALS: Storm Inspections Form 112 08.23.16 Page 3 of 5 SECTION 5: FINANCIALLY RESPONSIBLE PARTY INFORMATION The Owner of the subject property authorizes the following person or firm as the Financially Responsible Party for this Land Disturbing Permit. The Financial Responsible Party shall receive service of any notice, process, civil assessment or pleading in any action or legal proceeding arising out of any matter relating to the Land Disturbing Permit issued under this permit application and Unified Development Ordinance, Article 9.4. Brian Keel Chief Financial Officer FINANCIALLY RESPONSIBLE PARTY TITLE YMCA of the Triangle Area, Inc. 919-719-9622 COMPANY, IF APPLICABLE TELEPHONE NUMBER 801 CORPORATE CENTER DR STE 200 N/A STREET ADDRESS (NO P.O. BOX) FAX NUMBER Raleigh, NC 27607 brian.keel@ymcatriangle.org CITY, STATE, ZIP E-MAIL ADDRESS The undersigned acknowledges that he is the Financially Responsible Party for permit implementation, compliance and enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance, Article 9.4. He has read and understands the statements and disclosures made in this form, that the information disclosed herein is true and correct to the best of his knowledge and belief. This form must be signed by the person or firm financially responsible for the land developing activity or other person with authority to execute instruments for the financially responsible party, if not an individual. T ' he l�tip. day of MA'I' , 20 23 . 4110. - CIALLY RESPONSIBLE PARTY SIGNATURE TITLE IN WITNESS WHE EOF, th undersigned Notary Public has hereunto set his hand and seal, this 15- day of , 20 otary Pu lic(print name) / N tary Phu lic ' nature My Commission Expires:q? rp\ (;k , -eir fklOsa/11) Nota Public Title Posion Q If ( T5AR)- y`�ti= U COMMISSION EXPIRES 0 S. GG �2/2026 PROPERTY OWNER'S INITIALS: '•, PUBLIC U�� SlorunvaterInspectionsForm 112 ��j�/Ilgt�lJN,,```��? ,r 08.23.16 Page 4 of 5 SECTION 6: APPLICANT/PERMITTEE The Owner of the subject property authorizes the following person or firm as the Applicant/Permittee to receive service of any notice, process, civil assessment or pleading in any action or legal proceeding arising out of any matter relating to the Land Disturbing Permit issued under this permit application and Raleigh Unified Development Ordinance, Article 9.4. The Applicant/Permittee designated below is the person responsible for implementation of permit conditions and violation under Article 9.4 of the Raleigh Unified Development Ordinance. The Applicant/Permittee may be the landowner or another party who acknowledges that he is the Contractor responsible for completion of the project as approved. Tim Carr SVP Real Estate Developent& Facility Management APPLICANT/PERMITTEE TITLE YMCA of the Triangle Area, Inc. 919-345-5596 COMPANY, IF APPLICABLE TELEPHONE NUMBER 801 CORPORATE CENTER DR STE 200 N/A STREET ADDRESS (NO P.O. BOX) FAX NUMBER Raleigh, NC 27607 tim.carr@ymcatriangle.org CITY, STATE, ZIP E-MAIL ADDRESS The undersigned acknowledges that he is the Applicant/Permittee for permit implementation, compliance and enforcement resulting under the Land Disturbing Permit listed above and Unified Development Ordinance, Article 9.4. He has read and understands the statements and disclosures made in this form and that the information disclosed herein is true and correct to the best of his knowledge and belief. This form must be signed by the person or firm responsible for the permit or by a person with authority to execute instruments for the Applicant/Permittee, if not an individual. This, th 15 L- day of 11AP-CM , 201:5 . Svr C nt.t5/. cvGi . efIG LAI i 11,�r1t- APPLICANT/P RMITTEE SIGNATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal,this day of a'teJi , 20 .0 . V\f n M(.�•f -v.1(w\ t- Notary Pu lic(print name) No ry Publ c Si nature My Commission Expires: J / 4 N .R Notary Pubs Title/Position dtA yi oN EXPIRESO is a V coMM121S� 6 PROPERTY OWNER'S INITIALS: � � P1B1.�G ;``: StormwalerInspectionsFo08.23112 .16 � COUN'� ;�� Page S of S 111,,,III1111111N��