NCC220283_FRO Submitted_20220114

JCN
Durham City/County (OfAceU" Only)
Sedimentation and Erosion Control
j FINANCIAL RESPONSIBILITY/OWNERSE9P FORM
WITH LANDOWNER CONSENT FORM
No person m ayinitis teany land -disturbing activity coveredby theDurhamCity-CountyUnified Development Ordinance befcire a
Land DisturbingPexm it is issued by the SedimentationandErosionControi Office.Issuaneeofa LandDisturbingPermit doesno t
relieve the p ennittee ofthe obligation toobtain any otherficenses,permits andapprovals as maybe required by Federal, State,
County or Munic4Wgovemments. This office must benotifiedinwriting ofany change totheinfennationonthisform
PLEASE TYPE OR PRINT
1. Projectname: Trails at Turin Lakes
2. Roitdlocadonofland-distmtingactivity:- Charlestown Road and NC 98
Tax Map -Block -Parcel: 1313005558113000091
3. Square. footage ofland tobedisturbed oruncovered: 522,7205F
PIN: 0841-55-82-5638
4. List below the landownerofrecord. Each landownermustcomplete Item 8.
(Ifthere are multiple owners, please list on a sepamtepage):
not es n c 11 c l e. s I-� w h e_ D w r kajNq
Name- _. _—
PO BOX 52328_ -
Address
Durham NC 27717
City _ - - - State zip
III q-2b"7-2IZI -it `i_-y`�3-kG..33_. Email �ryye
i ���re
Telephone - Fax �5���.Ss'cx�•cc�v►�
S. List the person or entity financ(allyresponsiblefor Waland-disturbing activity: The fnandallyraesponsffileParty shall
be the deveioperorotherpersonwhohasorholdsthemwlvesasbavftfmamialoropemiional control over the land-
disturbiog activity and/or (2) the landowner or person in possession or control of the land when they have dimotly or
indirectly allowed the land4shubingactivityorhavebenefiitedf -om it and (3)the named party on the Land Disturbing
Permit.
Village Capital Corporation
Name
770 3rd Ave SW
SireetAddress
C�tntel IN
City State
317-7.05-7933
Telephone Fax
46032
zip
ablrge@.pedcor.net
--- Email
The Sedimentation and Pollution Control Act (Act) and the Durham City -County Unified Development Ordinance
(Ordinance) includes, but is not limited to, the followinglegal obligations ofthe finaucialty responsileparty:
• Maimtanuaset ofappmvedsedimentationanderosioncontrrolplans,ifrequimd,onsite.
■ Displaypermitonsite.
■ Understand and innpiement any requiredplan, including the constructionsequenceanddetails.
• Inspect,mairrtainandrepairsedim"tionanderosioncontmlmeastnes,especi*afterrainfisllevenU.
• Provided adequate groundcoverorotherwisestabilkeallar+easthathavenotbeenactiveiygradedwithin 21 calendar
days.
201 E. Main S451h Floor, Durham, N.C. 27701a [phone] a Far(91M60-0740
www.w.darb wn.ne.ashmg

■ Plan and conduct allland-disturbing activity soastoprevent off -site sedimentation.
6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
Ale
City
M - �1 x
Telephone
550
State
t4A FAK
Fax
Z-7&08
Ema
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 theperson or entity listed on Line 5 above will be: (1) the ownerof the Land Disturbing Permit when is sue d ;
(2) responsible for ensuring comphancewith the Act and Ordinance; and, (3) will be the only person or entity withstanding to
appeal any action taken or decision made by the Sedimentation and Erosion Control Office.
? 13 2-1 ,I*A f . Nr
Date Type or Print Nam e
3i�-S8? -0320 sve
Telephone L Fax Title r uthority
ru (�
EmailSignature
Business Apnlicant(Provide co rate resolution on siggatojy authority)
I, �i I g6n.S z allotaryPublic of the County of
State of .TILjd&^&G_ ,hereby certify that iSW
personally came before me this day and acknowledged that ie is
of V 11 l a•Pit LorL Yam► 0ft-gnjjW and acknowledged, on behalf of JA A ter
the due execution of the foregoing in strument.
Witness my hand and official seal, this 13 dayof A 20
XR C
NotaryPulffc
My commission expires , 20 2
Individual Applicant
I,
State
a Notary Public of the County of
hereby certify that
personally a ppmed b efo re m e this date a nd u nder o a th a cknowledged that the above form was ex ecuted by them.
Witness my hand and officialseal, this
My commission expires
dayof
NotaryPublic
20
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
20
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Provide a Notarized item S for each landowner listed in Item 4.
S. Land Owner Consent. Asa landowner, I provide myconsentfor nd-dist ing activities to occuron the property listed in
Item 2 by thepersonorentitylisted in Item 5. &f— '-
Date Re or; tName
Telephone Fax orAuthoriit
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Irtdividu�Landmvner
I, ,aNotary Public ofthe County of
Sta to of . hereby certify that
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Witness m y hand and official seal, this
My commission expires
20
dayof
Notary Public
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SR-03 Rev.87JO6