NCC231327_FRO Submitted_20230505

M JCN
NTY ` Durham City/County (Office Use Only)
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: Harris Teeter Fuel #224 - Hope Valley
2. Road location of land-disturbing activity: 7115 NC-751
Tax Map-Block Parcel: 135735 & 135736 PIN: 0718-18-64-3192 & 0718-18-62-4537
3. Square footage of land to be disturbed or uncovered: 68,830 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):
Harris Teeter Properties, LLC
Name
701 Crestdale Road
Address
Matthews North Carolina 28105
City State Zip
704-844-3100 jphares©harristeeter.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.
Harris Teeter Properties, LLC
Name
701 Crestdale Road
Street Address
Matthews North Carolina 28105
City State Zip
704-844-3100 jpharesAharristeeter.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.
• Refer to Section 12.10.4B 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., 1st Floor,Durham,N.C.27701 •[phone]•Fax[phone]
www.dcon c.gov/index.aspx?page=180

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Harris Teeter Properties, LLC
Name
701 Crestdale Road
Street Address
Matthews North Carolina 28105
City State Zip
704-844-3100 [e-mail]
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.
dacob Vigor es
ItztAtil-11)1,1-1U -VN Vrrs n�en1— M. Deal istatc)
'I:elpaft S Q ham s I Q l' c a l I I Fax Title o ority
Email Si
******************************************************************* *********************************************************
/
Business A licant(Prov'deccor_10 ate resolution on si or,authorit
I, JQnn\e)( k.� 'ODA r a Notar ublic of the County of 140, \{�xl�Vr
8
1 n Wn
State of i t)1 �lr(�me , ,hereby certify that J Db 1)\-\ r
``,,�llala�aillllllry�,came before me this day and acknowledged that he is A 1�Rvee;\ 8 \
,,,�� .. f 'n g l l f\S—reel 1 �i` ' W> LL
• lte rD r �i d acknowledged,on behalf of
:437 \,y s
_a'( ,the due execution of the foregoing instr ment.
2d✓imos m i$nd official seal,this 27 d of \ ,20
af.))--
,.�• p SA.'.
Vt.'........ V`-���,.„ ary Pubh
4vsa, tnt5sion expires Novex11\(\er \-1 ,202
*********************************************************************************************************************************
Individual Applicant
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 day of ,20
Notary Public
My commission expires 20
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.
11C)--i—aa( ncoy- mare
Type cr_Prt419-114.9i1AU v cv hens► m n 4 'Re a 1 Esrat-c)
Tel n Fax Title or t
mail Si
Business Landowner(( (Provide cor orate resolution on sig oiy authority) v
I. jtimN t r A. %(G4b caa Notary Public of the County of e.e, 1 l'f?r1hoY."
State ofNDCY`1 n rt l lQ. hereby certify that J D..cob-wares
personally came before me this day and acknowledged that he is j i C e re.\C�.€h k-
�iinnrr..� r� T- \ e I
a�y��t)�; ` Ve�( CCbrr\-iQS� acknowledged,on behalf of .CC 1S l e2Tcr �r� C VA.-es �L�
. ••/M n s0 ,the due execution of the foregoing instrument.
i 1 1. i Cessin han$iid5official seal,this Z l day o r 1 20'2
s s PUd�'\� .� ..
s� 'S 1'•�J�s
's No ry Public
`'�iur, `expires �bWeYY\\ner \i ,2025
.*********************************************.**********************************************************************************
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 day of ,20
Notary Public
My commission expires 20
SE-03 Rev.10/13