NCC222080_FRO Submitted_20220604

Re
Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
PROJECT LATITUDE: 35.9984
PROJECT LONGITUDE:—78.7271
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: Bucklin Residence
2. Road location of land -disturbing activity: 1800 Wentz Drive Durham NC 27703
Ta* Map Week - Parcel:
193984
3. Square footage of land to be disturbed or uncovered: 52,000 sf
PIN: 0881-08-73-2813
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
Edward R. Bucklin Jr.
Name
4820 Sandberry Lane
Address
Raleigh NC 27613
City State Zip
919-906-6659 n/a [e-mail]
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.
L and L of Raleigh, Inc.
Name
2301 Stonehenge Drive, Suite 107
Street Address
Raleigh NC 27615
City State Zip
919-841-4901 919-841-4902 [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:
■ 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.
201 E. Main St, 5" Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.co.durham.nc.us/ceng

4. List below the landowner of record. Each landowner must complete Item 8.
(if there are multiple owners, please list on a separate page):
Susan E. Dufur
Name
4820 Sandberry Lane
Address
Raleigh NC 27613
City State Zip
919-906-6659 n/a [e-mail]
Telephone Fax Email
4. List below the landowner of record. Each landowner must complete Item 8.
(if there are multiple owners. please list on a separate page):
Wanda T. Crumpler
Name
4820 Sandberry Lane
Address
Raleigh
NC
27613
City
State
Zip
919-906-6659
n/a
n/a
Telephone
Fax
Email

■ 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.
6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
James Warren Smith, III
Name
2301 Stonehenge Drive, Suite 107
Street Address
Raleigh NC 27615
City State zip
919-841-4901 919-841-4902 [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.
May 3, 2022 James Warren Smith, III
Date Type or Print Name
919-841-4901 919-841-4902 President
Telephone Fax Title or Au ority -.;C—
[e-mail] Wa,—4- --
Email
Signature
,���� �p,4 N M
Business Applicant (Provide corporate resolution on si ng atory authority) �N
I, Cameron M. Rice , allotary Public of the County of Wake
State of North Carolina ,hereby certify that James Warren Smith, III PUBLIC
personally came before me this day and acknowledged that he is President
of L and L of Raleigh, Inc. and acknowledged, on behalf of L and L of Raleigh, Inf/e CwTn�,t�\��``
Witness my hand and official seal, this
the due execution of the foregoing instrument.
day of MaY 20 22
Notary Public
My commission expires September 7 , 2024
I,
State
3rd
a Notary Public of the County of
hereby certify that
personally appeared before me this date and under
Witness my hand and official seal, this day of
commission expires
20
above form was executed by them.
Notary Public
20
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.
May 3, 2022 Edward R. Bucklin Jr.
Date Type or Print Name
01 Q-onr,_Kr a n/A 4-Ai-4A.—I
i cicpuvuc r as i ui nu yy�
[e-mail] `''
Email Signature
I,
State of
(Provide corporate resolution on signatory authority,
, a Notary Public of the County of
personally came before me this day
of
Witness my hand and official
commission expires
Individual Landowner
I,Cameron M. Rice
, hereby certify that
wledged that he is<forego
and acknowle the execution of t
day of
Notary Public
.20
a Notary Public of the County of Wake
State of North Carolina —,hereby certify that Edward R. Bucklin Jr.
20
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 3rd day of May , 2022
Notary Public
My commission expires September 7 20 24*ON
1iw
SE-03 Ve Rev.07/06
NOTARY
PUBLIC _
1111Nt�

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.
May 3, 2022 Susan E. Dufur
Date Type or Print Name
919-906-6659 n/a Individual and Spouse
Telephone Fax
.com
Email
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I,
State of
(Provide corporate resolution on signatory authority
a Notary Public of the County of
hereby certify that
personally came before me this day and aRknewLedged that he is
of
Witness my hand and official
and
-QulSehalf of
of the foregoi
_ day of _
Notary Public
commission expires 920
Individual Landowner
I, Cameron M. Rice , a Notary Public of the County of
Wake
State of North Carolina , hereby certify that Susan E. Dufur
20
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 3rd day of May 12022
Notary Public
My commission expires September 7 20 24
0 N
5E-03 =-Cj �.�� Rev.07/06
PUBLIC
�=
LIC
G

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.
May 3, 2022 Wanda T. Crumpler
Date Type or Print Name
n/a n/a Individual
Telephone
n/a
Email
1, -
State of
am
(Provide corporate resolution on signatory authority)
personally came before me this day
of
Witness my hand and official
a Notary Public of the County of
hereby certify that
ledged that he is <forego
and acknowle the ecution of t
day of
Notary Public
ission expires 120
20
*********************************************************************************************************************************
Individual Landowner
I, Cameron M. Rice a Notary Public of the County of Wake
State of North Carolina , hereby certify that Wanda T. Crumpler
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 3rd day of MaY 20 22
Notary Public
My commission expires September 7 20 24 MI��i,
SE-03 ` �j� Cam„ Rev.07/06
NOTARY
PUBLIC
I11