NCC222912_FRO Submitted_20220815

tT
Financial Responsibility Ownership IE ENGINEERING
(Sedimentation Pollution Control Act) SERVICES
E One Exchange Plaza, Suite 304
Raleigh, NC 27601
This sed► Dn to be Dorn ed b CAf orRetel h start
Submittal Date Effective Date
Transaction Number Permit: Number LD-
The remaining sections to be cump6lated by the Appikafif
SECTION 1: GENERAL INFORMATION & 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 and/or 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 date as designated above by the City of Raleigh. No rights
and liabilities associated with any designation shall incur until the effective data, 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 Owner's Association as the Applicant/Permittee 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, if information on the form is not applicable, place N/A 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 Z:
PROJECT INFORMATION
PROJECT NAME Town Center Apartments
PERMITTED PHASE(S) 1
PROJECT ADDRESS 6420 Capital Blvd
WAKE NUMBER S)I`I PARCEL ID 1727624709
DATE
PROJEICT PATED INITIATION F Apri 12022
EXPECTED DURATION OF PROJECT 20 Months
ACREAGE OF LAND TO BE Q .
DISTURBED Q
PROPERTY OWNER'S INITIALS:
Stormwaler Inspections Form 112
08.01.16
Page 1 of 5

SECTION S: PROPERTY OWNER INFORMATION
Ethel Limited Partnership
PROPERTY OWNER OF RECORD
1517 Caswell Street
MAILING ADDRESS (NO P.O. BOX) TELEPHONE NUMBER FAX NUMBER
Raleigh, NC 27508
CITY, STATE, ZIP
E-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 orby a person with authority to execute instruments, if
the Owner Is not an Individual
This, the _ �� day of 2t7 1_
PROPERTY MNER SIGNATURE TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this
644- day of Deeet?z ber . 2 D_f/_-
� P ta{ In r
r'
Notary Public (print name)
My Commission Expires; j �O0?-
PROPERTY OWNER'S INITIALS:
a ub4r-e
Notary Public itle 1 Position
KIM KEENA
Notary Public
for the State of Montana
— =
0 SEAI,-
Residing at:
Rlii�tan, Montana
a�en0N��
My Commission Expires:
,.,, ,.,.,
November 7, 2024
Stormwater Inspections Form 112
08.23.16
Page 2 of S
nU

SECTION 4' OWNER'S APPOINTED AGENT INFORMATION
The Owner of the property upon which land -disturbing activities will be undertaken is required 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 property hereby appoints the following person as an agent to receive service of any
notice, process, or pleading in any action or legal proceeding 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 agent and such service shall have the same force and effect as if
service was accomplished upon the Owner.
Adam Pike
NAME
The John R. McAdams Company
COMPANY, IF APPLICABLE
One Glenwood St Suite 201
STREET ADDRESS (NO P.O. BOX)
Raleigh, NC 27603
CITY, STATE, ZIP
Project Manager
TITLE
919 395 2272
TELEPHONE NUMBER
FAX NUMBER
[e-mail]
E-MAIL ADDRESS
The undersigned acknowledges that he/she is the Owner's appointed agent.
This, the S day of 4el v .20 7-4
7�
APPOINTED AGENT SIGNATURE TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his/her hand and seal, this
_day of C�!nn _ 20 21
Notary Public (print name) Na'f ry Public
{r�Signature -, [[
My Commission Expires: 21 Pyu C74�� 1�L Q. \a]i C.iGIA(rO�S
Notary put3lic Titl /PositionAN De
If�r
�0TAF; y,
PUEl00 _
(SEAL) C�
PROPERTY OWNER'S INITIALS! Slormwaler fnspeclions Form f f2
08.23. f5
Page 3 of 5
Iv

SECTION 5: 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 9.4.
IVP/Wood Town Center, LP
FINANCIALLY RESPONSIBLE PARTY
TITLE
IVP/Wood Town Center, LP
919-355-0110
COMPANY, IF APPLICABLE
TELEPHONE NUMBER
1414 Raleigh Road, Suite 429
STREET ADDRESS (NO P.O. BOX)
FAX NUMBER
Chapel Hill, NC 27517
[e-mail]
CITY, STATE, ZIP
E-MAIL 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 the �r 154' ��day of I�PC�rYI .. . 20 1 1
FINANCIALLY RESPONSIBLE PARTY SIGNATURE TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this
S�day of pP(Pvn be T 20 2-1_.
etVlyrmi+- Medli '& V iscoii+-i
Notary Public (print name)
My Commission Expires: No 111`/96
PROPERTY OWNER'S INITIALS:
Notary Public Signature
NOury�Lc- _
Notary ublic Title / Position
Stormwater Inspections Form 112
08,23.16
Page 4 o f 5
v

SECTION 6: APPLICANT / PERMII'TEE
The Owner of the subject property authorizes the following person or firm as the Applicant/Permittee 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 Applicant/Permittee 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.
IVP/Wood Town Center, LP
APPLICANTIPERMITTEE TITLE
IVP/Wood Town Center, LP 9.19-355-0110
COMPANY, IF APPLICABLE TELEPHONE NUMBER
1414 Raleigh Road, Suite 429
STREET ADDRESS (NO P.O. BOX) FAX NUMBER
Chapel Hill, NC 27517 [e-mail]
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, the (� day of �> — -v!!
J�JJOOY7
APPLICANTIPERMITTEE NATURE TITLE
IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this
�- day of bel , 20 f-1
F�ft1tM1 F- Rain V ISC6✓�i'i I ! .�r
Notary Public (print name) Notary Public Signature
My Commission Expires: 001 IT2—L_
PROPERTY OWNER'S INITIALS: _
NbW' t-u b li c— --
Notary Public Title / Position
Slormwaler Inspections Form 112
08.23.16
Page 5 of 5