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Home My WebLink AboutNCC215549_FRO Submitted_20211006Financial Responsibility Ownership 4q% ENGINEERING (Sedimentation Pollution Control Act) SERVICES One Exchange Plaza, Suite 304 Raleigh, NC 27601 This section to be completed by Ci(y of Ratei h staff Submittal Date Effective Date Transaction Number Permit Number LD- The remaining sections to be completed by the 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 NAME 400 H PERMITTED PHASE(S) 1 PROJECT ADDRESS WAKE COUNTY PARCEL ID NUMBER(S) PROJECT INFORMATION 414 Hillsborough 1703591309,1703 ANTICIPATED DATE OF o5/2020 PROJECT INITIATION EXPECTED DURATION OF PROJECT ACREAGE OF LAND TO BE DISTURBED 2 years 1.16AC PROPERTY OWNER'S INITIALS: Slormuvater Inspections Form l 12 0801.16 Page l of 5 SECTION 3: PROPERTY OWNER INFORMATION BR Hillsborough Partners LLC PROPERTY OWNER OF RECORD 104 Lake Cliff Ct. 919-460-9786 MAILING ADDRESS (NO P.O. BOX) TELEPHONE NUMBER FAX NUMBER Cary, NC 27513 gsandreuter@nc.rr.com 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 day day of 20 <Z_k -A+"— PROP NER SVNATUikE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this 2,41 ` day of FV6qVJVi✓4 2070 J A60vocua W Mk Ah-t Notary Public (print name) No try P iic Signature My Commission Expires: 2,z- AA>M_ :. N. ArX9%_&r*& Notary Public Title / Position PROPERTY OWNER'S INITIALS• { Stornnvaler Inspections Form 112 082316 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. Joe Puckett NAME Stewart COMPANY, IF APPLICABLE 223 S. West Street, Suite 1100 STREET ADDRESS (NO P.O. BOX) Raleigh, NC 27603 CITY, STATE, ZIP Practice Leader, Civil Engineering TITLE 919-866-4829 TELEPHONE NUMBER FAX NUMBER jpuckett@stewartinc.com E-MAIL ADDRESS The undersigned acknowledges that he/she is the Owner's appointed agent. This, the day of 1 �A'l j-- f� APPOINTED AGENT SIGNATURE 20 ZO ytw per Pb1.J7 _ TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his/her hand and seal, this day of Q(QMk" - 20 Z d . Wivil!606 Notary Public (print name) My Commission Expires C1 '5—, yy PROPERTY OWNER'S INITIALS: Nota P lic Signature A0%A 60 . kiT -T� Notary Public Title / Position Slornmvaler Inspections Form 112 08.23.16 Page 3 of 5 SECTION 5: FINANCIALLY RESPONSIBLE PARTY INFORMATION y 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. Gregg Sandreuter FINANCIALLY RESPONSIBLE PARTY BR Hillsborough LLC COMPANY, IF APPLICABLE 104 Lake Cliff Ct. STREET ADDRESS (NO P.O. BOX) Cary, NC 27513 CITY, STATE, ZIP Member Manager TITLE 919-460-9786 TELEPHONE NUMBER FAX NUMBER gsandreuter@nc.rr.com 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 �etl 20. FINANCIAL 5 NS[ LE P TY SIGNATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this 2AT` day of QOg66/" . 20'Z 0 ,�I AA,,'VK W AA l Notary Public (print name) Notar�Signature My Commission Expires: A0 Notary Public Title / Position PROPERTY OWNER'S INITIALS: E IV '� •yS1o1Y � . G NOTARY{�V,tA R F (USL G 4411lr. e 1 i NI Slormu•aler /nspections Form 112 0823.16 Page 4 of 5 SECTION 6: APPLICANT I PERMITTEE J 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. Gregg Sandreuter APPLICANT/PERMITTEE BR Hillsborough LLC Member Manager TITLE 919-460-9786 COMPANY, IF APPLICABLE TELEPHONE NUMBER 104 Lake Cliff Ct. STREET ADDRESS (NO P.O. BOX) FAX NUMBER Cary, NC 27513 gsandreuter@nc.rr.com 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, the day of 20 �. f _ t APPLICANT/PEXMITVE §WKAtW TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this 2QT''day of 20 20 . Notary Public (print name) My Commission Expires: 9 -sr— 2 Z PROPERTY OWNERS INITIALS: q�5 ota Public Signature Notary Public Title / Position �r,,••` �,; i E VV `'•tip x ` PUBLIC ~',�•4 '••.°ads , r Stormuvater Inspections Fornn 112 08.23.16 Page 5 of 5