NCC221591_FRO Submitted_20220504

JCN
r i Durham City/County (Office Use Only)
Sedimentation and Erosion Control
[i I♦ 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 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: 41 Moore Drive Commercial Alteration
2. Road location of land -disturbing activity: 41 Moore Dr, Durham NC
Tax Map - Block - Parcel: 156982 PIN: 0739-85-90-8453
3. Square footage of land to be disturbed or uncovered: 522,720 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):
ARE -NC REGION NO 19 HOLDING. LLC
Name
PO BOX 847
Address
CARLSBAD, CA, 92018
city State Zip
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.
ARE -NC Oliver Sherrill. Senior Vice President. Regional Market Manager
Name
5 Laboratory Drive Ste 3200
Street Address
Research Triangle Park NC 27709
City State Zip
919-313-6645 919.993.3439 osherrill(@are.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.
201 E. Main St, 5" Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durham.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:
Oliver Sherrill
Name
5 Laboratory Dr Ste 3200
Street Address
Research Triangle Park NC
27709_
City State
Zip
919-313-6645 919-993-3439
osberrill arexom
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.
Date Ty e or Print Name
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Telephone Fax
91'1- 6 a9 - 7323
Email
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1, Sabrina- W JunV�nS , a Notary Public of the County of-urharn
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Witness m hand and official seal, this ?� y day of 3ankAartt 20
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Individual Applicant
1, _a Notary Public of the County of
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 day of , 20.
My commission expires
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.
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Business Landowner (Provide corporate resolution on signatory authority)
1, will) . N Amy-'mr' , a Notary Public of the County of —DuVlrlOtm
State of qC t"iii (;ArL)iiy100. , hereby certify that Oiiyer Sherri -it ^
personally came before me this day and acknowledged that he is ire fit5r'
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the due execution of the foregoing instrument.
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Witness my hand and official seal, this day of Wum , 20LIG
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Notary Public �i� N,,�_
My commission expires 3anUaY!4 '2-(0 , 20 2io ���f f 1 f 11111
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Individual Landowner
1, , a Notary Public of the County of
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 day of , 20
Notary Public
My commission expires 20
SE-03 Rev.07/06