NCC230223_FRO Submitted_20230215

DURHAM
COUNTY
E P_
• 18a1 •
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 govenunents. This office must be notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name:
--v O'V4 '/V kW" f I r.•,r 4 Sfrc.t
2. Road location of land -disturbing activity: 310 Jackson Street, Durham, North Carolina 27703
Plat Book/Page: 201/50 y.k cD061311n
Tax Map - Block - Parcel: Deed Book/Page: 3523/667 SAIL/4 G 2_ PIN: 0821-77-73-4021 • o$ 21 ' �� — y'i ' 8 I ti 3
Parcel ID:226524 .." 2-Z6S2i
3. Square footage of land to be disturbed or uncovered: 29,617 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):
City of Durham - General Services Real Estate Division
Name
101 City Hall Plaza
Address
Durham NC 27701
City State Zip
919-560-4197 919-560-4196
Telephone Fax Email
S. 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.
AS46V, PIacm
Name!
113 S. Wilmington Street
Street Address
City ' State Zip
V?- 3 Y I "If 90 A11A P S�:c • 0(5
Telephone Fax lEmail
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.
■ Refer to Section 12.10.413 of the Durham City/County UDO for groundcover time line requirements.
■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
120 E. Parrish Street, Law Bldg., I" Floor, Durham, N.C. 27701 • [phone] • Fax [phone]
www.dconc.gov/index.aspx?page=180

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
4LYE fen Pb coe
a17 e
a S- �,,dm:4l:6A
Street Address
City State Zip
Telephone Fax I 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_
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 Type or Print Name
R } 00 — r - 3 Z- 6 rry, w -
Telephone [=ax Title t ra
Email Signature
Business A ticant (Provide corporate resolution on signatory authority)
1, , „ . -A,\ a��, a Notary Public of the County of n
r(
State of n m _��-fl�� n , hereby certif r that
personally came before me this day and acknowledged that he is
of As�,�o and acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this Zl day of jv_\N • 202
Notary Public
My commission expires Any-. 1 -3 , 20 22 Z
Susan . Kohirausch
Wake County
North Camllna
Individual Applicant M CQmmission res 3r423
1, , 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 day of
My commission expires
20
Notary Public
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
20

Provide a Notarized Item 8 for each
8. Land Owner Consent. As a landowner, I provide my consent for
Item 2 by the person or entity listed in Item► 5.
22, 2022
Wanda S.
Date Type or Print Name ���i"N/.�1eC
919-560-4222 City Manager
Telephone Fax Tide I Authgft
Email
Signature
P, S iR/a�`.
Business Landowner rovide corporate resolution on si nato authori
I, � P - -t', S i]i S . %t� � t� , a Notary Public of the County of w';aVy, e
State of ��'� j/� � W (�[ , hereby certify that VV:2,#A'A,
personally came before me this day and acknowledged that pis �d MaW
of 111 d� and acknowledged, on behalf of [;t ' /Lk� GQl1N�x��`
'�7"1T[ 11111
, the due execution of the foregoing instrument.
Witness my hand and official seal, this �' day of 20 �d
Notary Public
My commission expires — , 20. ,>. .
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Individual Landowner
I, , 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
My commission expires
20
day of
Notary Public
20
SE-03 Rev.10113