NCC215314_FRO Submitted_20210927

Financial Responsibility Ownership
(Sedimentation Pollution Control Act)
This section to be com Wed b Cif of Raleigh staff
Submittal Date Effective Date
Transaction Number Permit Number I_D-
to be
ENGINEERING
SERVICES
On�Plaza, ExchangeRal
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.
PROJECT NAME
PERMITTED PHASE($)
PROJECT ADDRESS
WAKE COUNTY PARCEL iD
NUMBER(S)
ANTICIPATED DATE OF
PROJECT INITIATION
EXPECTED DURATION OF
PROJECT
ACREAGE OF LAND TO BE
DISTURBED
PROJECT INF,
Milburnie Ridge
lK
3231 Old Milburnie Road, Raleigh NC
1746-62-8360
PROPERTY OWNER'S [NIT ALS: Stmmvater hispecliolis F-W, 112
OS.01.16
Page I of 5

PROPERTY OWNER INFORMATION
SECTION 3:
Capital Properties of Raleigh II, LLC
PROPERTY OWNER OF RECORD
3724 National Drive Ste 220 (919} 618-2060
MAILING ADDRESS (NO P.O. BOX)
TELEPHONE NUMBER FAX NUMBER
Raleigh, NC 27612 [e-mail]
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.
is the Property Owner for permit implementation, compliance and
The undersigned acknowledges that he
turbing Permit and Unified Development Ordinance, Article 9.4. The
enforcement resulting under this Land Dis
Owner d the property upon which aanddisturbing disclosures activity
mrade in this undertaken states and form and that the information disclosed
read and understands the statements
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 �
day of Jo 0 , 20 .
PROPERT OWNER S E TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this
day of_ � - 20 _•
s
otary Pub is (prin name)
My Commission Expires: W0*N0_S_
Notary] pli tic
C11_,1otiv County
Notin G asc11n1) ?0�3
shy C01111111.S1i3 11:"x�}r�lli'w5121
PROPERTY OWNER'S INITIALS.
Notary Pubi c Sign re
_ u
Notary Public TItl 1 Position
(SEAL)
Stonmiater 1)ispectio)1s 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,
Paul Asche, P.E.
NAME
Bohler Engineering NC, PLLC
COMPANY, IF APPLICABLE
4130 Parklake Ave, Suite 130
STREET ADDRESS (NO P.O. BOX)
Raleigh, NC 27612
CITY, STATE, ZIP
Assistant Project Manager
TITLE
[phone]
TELEPHONE NUMBER
FAX NUMBER
[e-mail]
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
Notary Public (print name)
My Commission Expires:
20
Notary Public Signature
Notary Public Title I Position
(SEAL)
PROPERTY OWNER'S INITIALS: StorurtrnlerInspections Fornr 112
08,23.16
Page 3 oj5

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,
arising out of any matter relating to
civil assess itissued underthis permit applica9 or pleading in any action or legolnproceeding and Unified Development Ordinance, Article 9the Land
.4.
Disturbing Perm
David Stallings
FINANCIALLY RESPONSIBLE PARTY
Shenandoah Homes
COMPANY, IF APPLICABLE
President
TITLE
[phone]
TELEPHONE NUMBER
3724 National Drive Ste 220
STREET ADDRESS (NO P.O. BOX) FAX NUMBER
Raleigh, NC 27612
CITY, STATE, ZIP
david@shenandoah homes. us
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.
This, the day of � , 20�
FINANCI ESPO SIBLE PARTY SIGNATURE TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this
day of 20 �O -
&tom
Notary Public (print name)
My Commission Expires: 2-3
40ta Pu ' ature �^
Nary�publ itie / Position
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PROPERTY O�VNF,R'S INITIALS:
SloranVaie• 111speclio1�5 F017)1112
08.23.16
Page 4 of S

SECTION B `. APPLICANT/PER... MITTEE
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 di the Land e 9.4. The Applicant/ Perm ittee designated below Permit issued under this permit application
is the personFreieigh spons responsible Unified
for
Development Ordinance, Article 9. pp
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.
Doug Lawrie
APPLICANTIPERMITTEE TITLE
Shenandoah Homes/Capital Grading [phone]
COMPANY, IF APPLICABLE TELEPHONE NUMBER
3724 National Drive Ste 220
STREET ADDRESS (NO P.O. BOX) FAX NUMBER
Raleigh, NC 27612 [e-mail]
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.
T is, th day ofi,�'It�grr�_ 20.
CA R TEE ATURE TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this
�b day of 20
otary Public g re
�o—taftyPublic print nartq }
My Commission Expires:
Notary Public Titlei Position
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I 5ta�nx'ater luspeclrotts Poljtt 112
PROPERTY 01VNER'S INTrIALS. 08,23.16
page 5 of 5