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Home My WebLink AboutNCC221544_FRO Submitted_20220421Financial Responsibility Ownership Q4Jq1kk ENGINEERING (Sedimentation Pollution Control Act)SERVICES one Exchange Plaza, 5104c 3174 Raleigh, NC 27601 The remsinirrg secyons to be comple red by the App?rcag! _ SECTION 1: GENERAL INFORMATION i 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 andfor 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 Bate 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 Owners Association as the ApplicantlPermittee 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, d information on the form is not applicable, place NIA 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 INFORMATION PROJECT NAME Atlantic Springs Place Apartments PERMITTED PFiASE(S) O n e PROJECT ADDRESS WAKE COUNTY PARCEL ID NUMBER(S) 5591 & 5591 Atlantic Springs Road 1718-97-12271 1716-97-4878 ANTICIPATED DATE of July I PROJECT INITIATION y 2022 EXPECTED DURATION OF One year PROJECT ACREAGE OF LAND TO BE n . A DISTURBED a PROPERTY OWNL,R'S INITL4-Ls Sormµv rrr 1nYM dons Fam 112 U8.r11-16 Page 100 SECTION 3: PROPERTY OWNER INFORMATION Asprings, LLC PROPERTY OWNER OF RECORD 2111 HARROD STREET MAILING ADDRESS (NO P-Q. BOX) Raleigh, NC 27604-1725 CITY. STATE. ZIP TELEPHONE NUMBER FAX NUMBER F-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 h day of c- PROPERTY OWNER SIGNATURE 2t7_,L-2,_- aV,,1Q TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this I . day of 1+t"-3ry 20 17— j1r14,11-61, L - t- AJ-IIC(ci- 4V-t L._. 11, _SQbi) Notary Public (print name) My Commission Expires: Fe_�•u7V I fr'I 7021- Notary Pubic Signature - Notary PublicTitle! Position (SEAL) Victor L. Rodriguez Ortiz Notary Public Wake County, North Carolina My Commission Expires February 14, 2022 i f. PROPERTY OWNER'S LMMALS- Srornmater hurpecuam Form f12 pow ?, of 5 SECTION 4: OWNER'S APPOINTED AGENT INFORMATION ' The Owner of the property upon which land -disturbing activities will be undertaken is requirod 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 properly hereby appoints the following person as an agent to receive service of any notice, process, or pleading in any action or legal proceedng 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 agont and such service shali have the same force and effect as if service was accomplished upon the Owner. nla NAME TITLE COMPANY, IF APPLICABLE TELEPHONE NUMBER STREET ADDRESS (NO P.U. BOX) FAX NUMBER CITY, STATE, ZIP E-MAIL ADDRESS The undersigned acknowledges that hefshe is the Owner's appointed agent. This. the day of APPOINTED AGENT SIGNATURE 20 TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his/her hand and seal, this day of Notary Public (print name) My Commission Expires: PROPERTY OWYNI 's tNiiiALB 20 Notary Public Signature Notary Public Title i Position (SEAL) Sac^.r k'awr 1i gAN.7hm. F+arm I 1 08.V 16 /'Ggs 3 of -$ Notary Public (prinf name) My Commission Expires: z`6 SEC710N �' FINANCIALLY RESPONSIBLE,PARTY., INFORMATION, 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 9A. Chris Carlino COO FINANCIALLY RESPONSIBLE PARTY Dominion Reality Partners, LLC COMPANY, IF APPLICABLE 501 Fayetteville St., Ste#100 TITLE 919-845-3306 TELEPHONE NUMBER STREET ADDRESS (NO P.O. BOX) FAX NUMBER Raleigh, NC 27601 CITY, STATE, ,ZIP ccarlino@drp-lic.com EMAIL 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, t e day of , 20 A 2- . F14MCfALLY RESPONSIBLE PARTY SIGNATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this 1, day of 20a h. L 2 0, a,�� Notary Public Signature Qx"�'V pie Notary Public Title 1 Position 4� ,@iAF? Y O (SEAL) s Pul3oo v PROPERTY OWNER'S INITIALS: "��lIIIIlliltllti"' SiornmaterInspections Form 112 08,23,16 Page 4 of 5 SECTION 6: APPLICANT / PERMITTEE The Owner of the subject property authorizes the following person or firm as the ApplicanUPermittee 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 ApplicanUPermittee 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. Chris Carlino APPLICANT/PERMITTEE Dominion Reality Partners, LLC COMPANY, IF APPLICABLE 501 Fayetteville St:, Ste#100 STREET ADDRESS (NO P.O. BOX) Raleigh, NC 27601 COO TITLE 919-845-3306 TELEPHONE NUMBER FAX NUMBER ccarl i noted rp-Ilc.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, t �_ day of 20 AP (CANT/PERMITTEE SIGNATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this day of �04\u-kah 20 :L :L G. �S_. iv.& t —T� Notary ublic (print name) Notary Public Signature My Commission Expires: '-V t\tv_ Notary Public Title / Position PROPERTY OWNER'S INITIALS: �`�,p1NINIRl1lfltfp��' `' (SEAL) "2 r1Q�A Y PUC300 �v CQVNN��`3�ta Gispectinn.s Form H2 0 .23.16 Page 5 of 5