NCC215847_FRO Submitted_20211021

JCN
(Office Use Only)
111CR
Durham City/County
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITYIOWNERSHIP 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 pennittee 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: Tallman Residence
2. Road location of land -disturbing activity: 7410 Kennebec Drive
Tax Map - Block - Parcel:
PIN: 0707-03-24-3281
3. Square footage of land to be disturbed or uncovered: 105,000 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):
Joshua Tallman
Name
3806 University Drive Unit 459
Address
Durham NC 27707
City State Zip
_919-792-6352 [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 Iand-
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.
Joshua Tallman
Name
3806 University Drive Unit 459
Street Address
Durham NC 27707
City State Zip
_919-792-6352 [e-mail]
Telephone Fax Email
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.
201 E. Main 5t, 5t1 Floor, Durham, N.C. 27701 • [phone] * Fax [phone]
www.co.dnrham.nc.uslceng

■ Plan and conduct all land -disturbing activity so as to prevent off site sedimentation.
6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
Name
Street Address
City State Zip
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.
'L Joshua Tallman
Date Type or Print Name
_919-792-6352 Owner
Telephone Fax a or Authon'tu
ioshPbiuesourcesolar.com tom`
Email Signature
#t#iii#t#tt###t#t#tti##tit#t####►#i*►Rt#t*###t#t#R#RR#tit#t*rrrrrr�Yrssss+�isssssitri#tst#tt#i#tt►#i►i##t►#t#t#t#t##i#►ii#it#tttt#t#t
Business Applicant (Provide corporate resolution on signatory a thori
a Notary Public of the County of
State of hereby certify that
personally came before me this day and acknowledged that he is
of
Witness my hand and official seal, this
and acknowledged, on behalf of
, the due execution of the foregoing instrument.
My commission expires , 20
day of 520.
Notary Public
rrrsssrsrssswrrswrrsksssskssststrt#t##t#*s#s#tss###*##►#►#►#►#►#►#t►*i#►#►#s##isrtrtirtis#tit*t*####R#►#s###tsstt►ttttstttsssssrs
Individual Applicant r 1Li P. A S ln•.r►�0+� 5 , a Notary Public of the County of ora'n q
State offjoc . , 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 11— day of Q f:hQ b ta r , 20 Z t
Notary Public
My commission expires _ In [ (A 20 2 2
LAND DISTURBING PERMITS ARE NON-
*�� SIWj/y'��ii.
�kp�ARY _
"t,E
o PUBj-\G .=� -
O

Provide a Notarized Item 8 for each landowner listed in Item 4.
S. 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.
2
Date I Type or Print Name
_919-792-6352 Owner
Telephone Fax Title or Author' aa
[e-mail] tel.
Email Signature
rYk#s###rrYYSY#YY#rYrYY#Y#Yk#YrrY#Y#}}YYYY}Y#»#»»»»»»»#s#**»*»»##»s#»*»#»#»#»*»*»*»»»*»**»»*»*»#»s»»»*»t»»»*#»#s»»#»r##r*«#«#»#**#t
Business Landowner tProvide corporate resolution on signatory authorityl
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
Witness my hand and official seal, this
and acknowledged, on behalf of
the due execution of the foregoing instrument.
My commission expires , 20
day of 120
Notary Public
Individual Landowner
P•S I M w► 0t% S, a Notary Public of the County of 6 ccl a�i
State ofCara i i n CL , hereby certify that Q
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 1 -S day of CJZ b e 20 --:2—
r �• n`
Notary Public
My commission expires / d — / tp _ 2o 2, 2—
'��N��Irrrrr�0,
e" NOTARY
A e
a e
a +
+
O PUBLIC '
,V •