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HomeMy WebLinkAboutNCC230644_FRO Submitted_20230316Durham City/County Sedimentation and Erosion Control JCN (Office Use Only) [i r♦ 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: PROJECT BLUE JAY: PHASE 1 SITE AMENDMENT 2. Road location of land -disturbing activity: SO HI DRIVE 35.940584,-78.868978 Tax Map - Block - Parcel: 225017, 228347 3. Square footage of land to be disturbed or uncovered: 12.0 AC PIN: 0739-86-15-8174. RTP. 0739-86-15-8174.SRV 4. List below the landowner of record. Each landowner must complete Item 8. (If there are multiple owners, please list on a separate page): ELI LILLY AND COMPANY Name LILLY CORPORATE CENTER Address INDIANAPOLIS INDIANA 46285 City State Zip 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. Daniel Lee VonDielinaen Name 59 Moore Drive, P.O. Box 110047 Street Address Durham North Carolina 27709 City State Zip (317) 270-7522 vondielingen_daniel_I@lilly.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 . (919) 560-0735 . Fax (919) 560-0740 www.co.durham.nc.us/ceng ■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation. For business applicants, list below the North Carolina registered agent for the financially responsible entity: 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 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. —CJ _ 2d-2- Z Victor M. Cruz Date Type or Print Name (317)695-6070 Sr. Vice President -Corporate Engineering & Global HSE Telephone Fax Title orAuthority Cruz victor_m@lilly.com Email Signature ################################################################################################################################### Business Aunlicant (Provide corporate resolution on signatory authority) I, W\ 5'<Q\, , allotary Public of the County of QyN State of Ord,. 0rA , hereby certify that cv'Z 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 4e_c-emSt}tt' day of (� , 20 M-0 Notary Public My commission expires 12030 ##################################################################### at Individual Applicant 11. a Notary Public of the County of State of , hereby certify that +y''.., — PAULETTE M 5TULL My Commission Expires r = Commission Number NPM13M 'xo;iiq•' JohnsonCounly 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 LAND DISTURBING PERMITS ARE NON -TRANSFERABLE 20 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. —U 9 — ZO Z Z Victor M. Cruz Date Type or Print Name (317)695-6070 Sr. Vice President -Corporate Engineering & Global HSE Telephone Fax Title r Authority Cruz victor m@lilly.com��,—., Email ignature Business Landowner (Provide corporate resolution an signatory authority} I, _Ro")"jAy_ M '�� , allotary Public of the County of State of ',,..kN[-, G,re\' , 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. q-f:!` day of 162.C.QmhE C 20 2,2. Notary Public My commission expires Voo sQwz H a\ , 20 30 . ########k�lc#oF##cM#M►###►tlttafttttssrtrettdt#3d�rra rr##eree �►►###M#R##Fi##MF#MMk########aaa+a*aa* Individual Landowner I, State o a Notary Public of the County of hereby certify that t ....� PAULETTE M STULL i�iwiSA�alitatrt♦ My Commissian Expires � � FBhAiegk>74 e243D :v r ` ssfon NumherHPOfi5 Johnson County 930$ 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 day of Notary Public 20 20 5E-03 Rev.07/06