NCC217087_FRO Submitted_20211221

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 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: Marketplace at Ellis Crossing
2. Road location of land -disturbing activity: NE Corner of Ellis Road and Watchorn Road
Tax Map - Block - Parcel: 222525 PIN: 0749-01-37-2776
3. Square footage of land to be disturbed or uncovered: —12.35 Acres
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Ellis Rd Durham NC LLC
Name
901 Wabash Avenue Suite 300
Address
Terre Haute IN 47807
City State Zip
317-671-7223 bwilliams thorn sonthrift.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.
Ellis Rd Durham NC. LLC
Name
901 Wabash Avenue Suite 300
Address
Terre Haute IN 47807
City State Zip
317-671-7223 bwilliams .thorn sonthrift.com
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.
• Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
201 E. Main St, 51' Floor, Durham, N.C. 27701 ■ [phone] • Fax [phone]
www.co.durham.ne.us/ceng

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
Corporation Service Comnan
Name
2626 Glenwood Avenue Suite 550
Street Address
Raleigh NC 27608
City State Zip
302-636-5401 Aindrea.mancari ess lobal.com
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.
E
Paul M. Thrift
Date Type or Print Name
317-671-7223 Manager
Telephone Fax Title or Author
bwilliams thorn psonthrift.coTn
Email Signature Z /f I —
Business AoDlicant Pro ide corporate resolution on siF_nato authority)
1, , a Notary Public of the County of
State of hereby certify that ?AlwQ�vWL
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
otary FLblic
My commission expires 7 , 20
STEPHANIE LYNN PAUL
Notary Public - Seat
Henry County - State of Indiana
Commission Number 705028
My Commission Expires Sep 7, 2025

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 p�c'lb
son or entity listed in Item 5.
I q a I Paul M. Thrift, Manap-er
Date
317-671-7223
Type or Print Name
Telephone Fax Title or Authority /� ,
hwilliams(a,thompsonthrift.com I 17
Email
hereby certify that
personally came before me this day and acknowledged that he is
Signature
of
1 A■ 1
and acknowledged, on behalf of
, the due execution of the foregoing instrument.
Witness my hand and official seal, this 14 day of , 20
Notary blic
expires
My commission 20 ��5
E
NIE LYNN PAUL
y Public- Seal
ty-State of Indianaon Number 705028
on Expires Sep 7.2025
SE-03 Rev.07/06