NCC222137_FRO Submitted_20220617

JCN
(Office Use Only)
Durham City/County
Sedimentation and Erosion Control
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 Lots 9 10. 11
2. Road location of land -disturbing activity: NE Corner of Yunus Road and Watchorn Road
Tax Map - Block - Parcel: 222525 PIN: 0749-01-37-2776
3. Square footage of land to be disturbed or uncovered: —6.25 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.
201 E. Main St, 51h Floor, Durham, N.C. 27701 • [phone] a Fax [phone]
www.co.durharn.nc.us/ceng

■ 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:
Corvoration Service Comnan
Name
2626 Glenwood Avenue, Suite 550
Street Address
Raleigh NC 27608
City State Zip
302-636-5401 Aindrea.ilia ncari rt cS$R10 ial.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.
Ashlee Boyd
Date Type or Print Name -
317-671-7223 Authari7ed 24nTrRlipntsitivp-7
Telephone Fax 'I tle or A or
bwilliams thorn sonthrift.com
Email Signatu
Business Applicant (Provide corporate resolution on signatory authority)'r
I, ►��75 a Notary Public of the County of V f tr]
State of 2rA All a , hereby certify that be
personally came before me this day and acknowledged that he is A U or) &e
of EM s i�d ,DurhA ►n AL u.f, _and acknowledged, on behalf of &kejPkL 0 011 S � j /0) 9 (6,11
the due execution of the foregoing instrument.
Witness my hand and official seal, this 1 s� day of 1.1V 120
v{ I
NotPu is
My commission expires �� � � � , 20.
FAIN.1'.10-CLA
is
BL•ST TE OF INDIANA
SEAL
V100 COUNTY
O.Y N U M R r• R N P9147a9S
SIONLXPIRts 11-10-2077

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.
Ashlee Boyd
Date Tvpe or Print Name
Business Landowner (Provide corporate resolution on signatory authority,)
I, �jq �GI� ✓ S , a Notary Public of the County of
State of �Vl� l'a n ,hereby certify that
personally came before me this day and acknowledged that he is 4flY i ✓'Q .•'p-K-�:-44 Vq
of � S ✓�'Ouoka wl ' AfG and acknowledged, on behalf of A - 140- &-" ON �ot
Witness my hand and official seal, this
My commission expires l /— /6
the due execution of the foregoing instrument.
3 day of Q 20 0�0?
Notary Yublic
ANGELA M HARR:t"DIANA
NOTARY PI19L1C-STATE OF
SEAT.Vtoo Co1FCOMMISSIOVN UWIRE RH3
MYCOMMI SKION C%PIRES 20
SE-03 Rev.07/06