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HomeMy WebLinkAboutNCC232525_FRO Submitted_20230822 Financial Responsibility Ownership ; • i ENGINEERING (Sedimentation Pollution Control Act) SERVICES One Exchange Plaza,Suite 304 Raleigh,NC 27601 This section to be completed by City of Raleigh staff Submittal Date Effective Date Transaction Number Permit Number LD- The remaining sections to be completed by the Applicant 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 date, 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 2: PROJECT INFORMATION PROJECT NAME Allora Pines PERMITTED PHASE(S) PROJECT ADDRESS 2300 & 2310 Tryon Rd, Raleigh NC NUMBER(sU TY PARCEL ID 0792659674, 0792657338 ANTICIPATED DATE PROJECT INITIATION OF March 2022 EXPECTED DURATION OF PROJECT 24 months ACREAGE OF LAND TO BE DISTURBED PROPERTY OWNER'S INITIALS: )� Stormwater Inspections Form 112 08.01.16 Page 1 of 5 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. NAME TITLE COMPANY, IF APPLICABLE TELEPHONE NUMBER STREET ADDRESS (NO P.O. BOX) FAX NUMBER CITY, STATE, ZIP E-MAIL ADDRESS The undersigned acknowledges that he/she is the Owner's appointed agent. This, the day of , 20 APPOINTED AGENT SIGNATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his/her hand and seal, this day of , 20 Notary Public(print name) Notary Public Signature My Commission Expires: Notary Public Title/Position (SEAL) �j / PROPERTY OWNER'S INITIALS: ¶•I .) Stormwater Inspections Form 112 08.23.16 Page 3 of 5 SECTION 6: APPLICANT/PERMITTEE 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. CRP/MAPLE PINES OWNER LLC APPLICANT/PERMITTEE TITLE 8436877275 COMPANY, IF APPLICABLE TELEPHONE NUMBER 4509 CREEDMOOR RD STE 308 STREET ADDRESS (NO P.O. BOX) FAX NUMBER RALEIGH NC 27612 ewhite@tcr.com 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 ND v.. - 20 - r (-yolks Vic Pre s;c12,,�('!— APPLICANT/PERMITTEE SIGNATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal, this 1r1 day of NC .,xr , 2022 . .1Pet 401/6. Notary Public(print name) Notary Publ' Signature My Commission Expires: � ' - :2 Notary Public Title/Position SKAYA MOKMA NOTARY PUBLIC WAKE COUNTY,NC (SEAL) My Commission Expires 8-30-2027 PROPERTY OWNER'S INITIALS: Storn2water Inspections Fonn 112 08.23.16 Page 5of5