NCC233558_FRO Submitted_20231212

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
O WITH LANDOWNER N CO SENT FORM
• 1881
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 he notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name: Selby Ave Homes
2. Road location of land-disturbing activity: Extension of Selby Ave, Durham, NC
Tax Map-Block-Parcel: 133952 PIN: 0830-03-01-9867
3. Square footage of land to be disturbed or uncovered: 143,750
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
Ludlow South,LLC
Name
PO Box 4254
Address
Chapel Hill NC 27515
City State Zip
919-265-7029 jklaltman@gmail corn
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.
Ludlow South,LLC
Name
PO Box 4254
Street Address
Chapel Hill NC 27515
City State Zip
919-265-7029 [e-mail]
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,5`I Floor,Durham,N.C.27701 •[phone]• Fax[phone]
w w.co.durham.nc.us/ccng

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.
Ludlow South, LLC
Date Type or Print Name
919-265-7029 Manager
Telephone Fax Title or Authority
jklaitman@gmaitcom
Email Sig rn t e
Business Landowner(Provide corporate resolution on signatory authority)
I, 1_AvAr a \ oS1 r\ 0 ,a Notary Public of the County of t)yq
State of 1herebyJason Klaitman
+ r4� certifythat
personally came before me this day and acknowledged that he is Manager
of Ludlow South, LLC and acknowledged,on behalf of Ludlow South; LLC
the due execution of the foregoing instrument.
Witness myhand and official seal,this
L: day of n,±e,IrrAce.y L-- :c4
���� Notary Public
( Notary Public Orange Co., North Carolina
My commission expires / 7 ,20 My Commission Expires June 7,2027
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

■ Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation_
6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Ludlow South. LLC
Name
PO BOX 4254
Street Address
Chapel Hill NC 27515
City State Zip
919-265-7029 [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 he: (I)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.
11/06/2023 Jason Klaitman
Date Type or Print Name
919-265-7029 Manager
Telephone Fax Title or Authority
jklaitman@gmail com
Email Sigma \�1J'
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Business Applicant(Provide corporate resolution on si tatory authority)
I. l.11lan� 'kC, Ln 0 .a Notary Public of the County of Ore,rnce
State of �1-t (-" CionbV to ,hereby certify that Jason Klaitman
personally came before me this day and acknowledged that he is Manager
of Ludlow South,LLC and acknowledged,on behalf of Ludlow South,LLC
. the due execution of the foregoing instrument.
Witness my hand and official seal,this ' day of `r`kr_iy)o - ,20 93
.4/A,e 7H/ :L4 7
Notary Public
My commission expires L& _ .20 a� . LILIANA MOSINO
Notary Public
***R*RR.s..*.************************.....*m*****.***************.*...........*****4.**..,...4t...*4Orange.c.ot;Nerth.oaroli<ia
My Commission Expires June 7,2027
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