NCC243357_FRO Submitted_20241106

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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WITH LANDOWNER CONSENT FORM
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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:NC 55 and Hopson Building 3 Extension: Yes or n
2. Road location of land-disturbing activity:Hopson Road Extension and Roeben Road
Tax Map-Block-Parcel: 236714 AND 236718 PIN:0737012742 AND 0737028726
3. Square footage of land to be disturbed or uncovered:1,387.049 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):
Scannell Properties#539 LLC
Name
8801 River Crossina Blvd..Suite 300
Address
Indianapolis Indiana 46240
City State Zip
908-655-5632 317-843-5957 andvs(alscannellproperties.com
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.
Scannell Properties#539 LLC
Name
8801 River Crossina Blvd..Suite 300
Street Address
Indianapolis IN 46240
City State Zip
908-655-5632 317-843-5957 andvsfascannellproperties.com
Telephone Fax Email
X As the Financially Responsible Party, I consent to receiving notifications regarding this project via electronic
(Initials) communication at andvs(a.scannellproperties.com
(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.dur ham.nc.us/ceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Cogency Global,Inc.
Name
212 South Tryon St., Suite 1000
Street Address
Charlotte NC 28281
City State Zip
866-775-0114 866-775-0115
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.
/a ki Marc Pfleging
Date Type or Print Name
317-843-5959 317-843-5957 Manager
Telephone Fax Authori '
[e-mail] Tia,
Email Si nature
Business licant rovide co orate resolution on si ato authorit ���� �
I, /? .a Notary Public of the County of //40/n//%1/!
State of Indiana ,hereby certify that Marc Pfleging
personally came before me this day and acknowledged that he is Manager
LI \\\\��„ti...JAC ,/i
F� • ;of Scannell Properties#539,LLC and acknowledged,on behalf of Scannell Properties#539, s@�y . 5.....KC$1p S Otii,�
•
the execution of the foregoing instrument. :a•
, 4 "m..
IZ NOTARY
Witness my hand and official seal,this day of April 20 : , PUBLIC �,
3 y SAL c���'
Alp ,
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My commission expires ��'G%/ i G 3 20 �� iol ;; ;•��`
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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.
Date Type or Print Name
Telephone Fax Title or Authority
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
***************.......*********.......**************************************..........*****.*..*.....****************************
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