NCC216774_FRO Submitted_20211208

DURHAM
COUNTY
Edo
L•1881•
Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
FINANCIAL RESPONSIBILITY/OWNERSHIP 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 aQA
relieve the permittee of the obligation to obtailkany other licenses, permits and approvals as may be required by Federal, State,. 0 1,.
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: Braxton
2. Road location of land -disturbing activity: 1431, 1432, 1502, 1506 & 1518 Ellis Rd
Tax Map - Block - Parcel: 163357, 163356, 209141, 163355, 163366PIN:0739-02-89-8616 0739-02-89-67t8
7 - 5 54, 0 0-02-80-1161, 0830-03-90-3538
3. Square footage of land to be disturbed or uncovered: 1,316,383.2 SF (30.22 AC)
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Pule Home Company, LLC c/o Chris Raughley
Name
1225 Crescent Green Drive St. 250
Address
Cary NC 27518
City State Zip
919.816,1161 chris.rauahlev0pultegroun.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.
Pulte Home Company, LLC c/o Chris Raughley
Name
1225 Crescent Green Drive St. 250
Street Address
Cary NC 27518
City State Zip
919.816.1161 _ [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:
• Mairnain a set of approved sedimentation and erosion control plans, if required, ion site.
• Display permit on site.
■ Understand and implemerit any required plan, including the construction sequence and details.
Inspect, maintain and repair sedimentation and erosion control measures, especially after rainfall events.
■ Refer to Section 12.10.413 of the Durham City/County UDO for groundcover time line requirements.
■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
120 E. Parrish Street, Law Bldg., Vt Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.deonc.gov/index.aspx?page=180

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
Chris Raughley , VP L.oVn� pv,�,Q,u�yrt,t.�.yr , Fyj I 4-e., J+wle
Name
1225 Crescent Green Drive St. 250
Street Address
Cary NC
27518
City State
Zip
k
919.816.11 1`.i.;`
[e-mail]
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.
6/25/2021
Chris Raughley
Date
Type or Print Name
919.816.1161
Vice President of Land Development
Telephone Fax
Tj'tle or A rit
chr s.rau hle ulte rou .com
l / nw
Email
Signature
Business Applicant (Provide comorate resolution on sisnatory authori
I, 11 eit t 6,�n 4 wl -&o n .t , a Notary Public of the County of VV-1y_e.
State of NO✓+Nt (#/Yu n w , hereby certify that
personally came before me this day and acknowledged that he is , V 1 � _�v-e �i
of.
f ��� m r ,
�.BV;'1 _ , ,�� . , and'acknowledged, on behalf of T m
J
V(/G the due execution of the foregoing instrument.
Witness my hand and official seal, this 71— day of (- Vt yu_ 120
?--lf
j �} Notary Public
My commission expires J i./1l u Y 1 , 2fl_.
� / p, S ,c
`V •, /fj 4
Individual ApplicanQ TA R
a Notary Public of the County of = _
UBk-
State of , hereby certify that -9
COON
personally appeared before me this date and under oath acknowledged that the above form was ex'2�A�d+by`Kem.
Witness my hand and official seal, this
My commission expires
20
day of , 20
Notary Public
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE

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.
6/25/2021 _ Chris RaughleX _
Date _ .. Type or Print Name
919.816.1161 _ _Vice President of Land Development
Telephone Fax 'rr'- Title or AuNrity
Email Signature
Business Landowner (Provide corporate resolution on sienatory authori
I, M ell Sri SvA �,'L4 a Notary Public of the County of W!a
State of ML, hereby certify that C/h Vi 5 9SyLc i //�j__(4!!!!d
`
personally came before me this day and acknowledged that he is _(C. 6-G&i pU�i�til
of L6%,Yx01 and acknowledged, on behalf of "4±:h M - I4 m le Ct WIC
the due execution of the foregoing instrument.
Witness my hand and official seal, this S15- day of JtA, 20
Notary Public
Mycommission expires 1/( , 20
�*j
Individual Landowner = �;• _
a Notary Public of the County of G U
U ID
a
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
My commission expires 20
day of , 20
Notary Public
5E-03 Rev. 10113