NCC233435_FRO Submitted_20231117

JCN
Ost.:„/!:104 Durham City/County (Office Use Only)
isitwfwitm Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
`: ' r70 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:_Lightbridge Academy at Ellis Crossing
2. Road location of land-disturbing activity: Corner of Watchorn St &Yunus Rd
Tax Map-Block-Parcel:_DB 009444 PB 000205 PIN: 0749-27-64-4730
3. Square footage of land to be disturbed or uncovered:_65,000 SF
4. List below the landowner of record. Each landowner must complete Item S.
(If there are multiple ovs.ners,please list on a separate age):
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Name
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Ad rss
City Ste 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.
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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,5th Floor,Durham,N.C.27701 •[phone]•Fax[phone]
wtiwv.co.durham.nc.ustceng

■ Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
6. For business 5 applicants,list below the North Carolina registered agent for the financially responsible entity:
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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 ny acti n taken or decision made by the Sedimentation and Erosion ontrol Office. .
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Telephon.exl. iFax i e or Authority-I
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Email ignature
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Business Applicant(Provide corporate resolution on signatory authority) �(,
I, V`�-, ✓2.fr , a Notary Public of the County f /f s
State of P y hereby certify that ni)6 (z)5/1/)v
personally came before me this day and acknowledged that he is M
of rn. 02- l a-Po 1 1 I vO -L-C.and acknowledged,on behalf of /14 S0 2_ A a[ d t A9
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Witness my hand and official seal,this day of lc, qr. .,
Pu State of New Y. •
• Nota Qualified in Suffo ntaj.
My commission expires I 20 ommisslon Expires April 25,201.01
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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 S for each landowner listed in Item 4.
S. Land Owner Consent. As a landowner, I provide my consent for land-disturbing activities to occur on the property listed in
Ite rr?
2 by t e person or entity listed in Item 5.
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Email S ,nature
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Business Landoo�wner(Provide corpo ate resolution on signatory authority)
I, l 609h- , a Notary Public of the County of " --r"I
State of /�t_ hereby certify that Y"r S
personally came before me this day and acknowledged that he is y t e✓L
of m S py IA>a, P 1 At vo L1. -- and acknowledged,on behalf of S O - i� 61JO L-L_ C-
,the due .�ecution of the foregoing i tr "Ent.
my g` day 2�
Witness hand and official seal, this • of 20
/ t-'9:-Pei
Public State of New Yost
j �,�g Notary P c NO. 01FA6125867
My commission expires t �3 20 Qualified in Suffolk Courlty,L.I.
Commission Expires April 25,
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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 day of , 20
Notary Public
My commission expires 20
SE-03 Rev.07/06