NCC223562_FRO Submitted_20221014

Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
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 mustbe notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name: Farrington Multi -Family
2. Road locationof land -disturbing activity: 5580 Farrington Road
Tax Map -Block- Parcel: See Attached List
3. Square footage of land to be disturbed or uncovered: 393,923
PIN: See Attached List
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
TRG Farrinaton LLC
Name
322 East Chapel Hill Street
Address
Durham NC 27701-3302
City State Zip
919-884-7395 rstewart(a-_)trinsicres.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.
Ryan Stewart - TRG Farrington LLC
Name
322 East Chapel Hill Street
Street Address
Durham NC 27701-3302
City State Zip
919-884-7395 [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 me asures, especially afterrainfall events.
■ Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
201 E. Main St, 5th Floor, Durham, N.C. 27701 e [phone] • Fax [phone]
www.co.durham.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:
Name
Street Address
City State Zip
Telephone Fax Email
7. The above information is true and correct to the best of my knowledge and belief and was providedby me while underoath. 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 ordecision made by the Sedimentation and Erosion Control Office.
9/28/22 Ryan Stewart
Bate Type or Print Name
919 884-7395 ManagingMan2ging Director f Vice esiden
Telephone Fax1-Tiffe-
[e-mail]
Email Siatu0
Business Applicant (Provide cotporateresolution on signatory authority)
I, , a Notary Public of the County of
State of
, hereby certify that
personally came before me this day and acknowledged that he is
of
Witness my hand and official seal, this
and acknowledged, on behalf of
, the due execution of the foregoing instrument.
day of 120
Notary Public
My commission expires , 20
Individujo An licant
f
1, t� A/�i' �V�I/ h a Notary Public of the County of
State of Y, hereby certify that f ,
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand andofficial seal, this day of � � � 20 d d—
Notary Public ,��tt►u��tt���i�
My commission expires 1 20 d ��� ,�.5 .«».�,�✓ �i,
LAND DISTURBING PERMITS ARE NON-TRANSFERA) * ° 4 �A
AUGUS1 202A 25
too

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.
Date
Telephone
Email
Fax
Type or Print Name
Title or Authority
Signature
...................................................................................................................................
Business Landowner (Provide comorate resolution on sienatory authorit
I, , a Notary Public of the County of
State of ,hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged, on behalf of
, the due execution of the foregoing instrument.
Witness my hand and official seal, this day of 120
NotaryPublic
My commission expires ,20
.................................................................................................................................
Individual Landowner
I, , a Notary Public of the County of
State
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
My commission expires
20
day of ,20
NotaryPublic
5F,03 Rev.07/06