NCC240161_FRO Submitted_20240118

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
13E0 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
"� WITH LANDOWNER CONSENT FORM
lasl
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: Camden Industrial Extension: No
2. Road location of land-disturbing activity: 1716 Camden Avenue,Durham,NC 27712
Tax Map-Block-Parcel:
PIN(s): 0832-85-92-2477,0832-84-69-0551, 0832-84-15-2152,0832-74-64-3794, 0832-74-63-8830,0832-74-63-2289
Lat and Long of Project: 36.017, -78.87
3. Square footage of land to be disturbed or uncovered: 1,208,790 sf(27.75 ac)
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
Name: Camden Industrial,LLC
Address: P.O. 10440
City: Greenville State: South Carolina Zip: 29603
Telephone: [phone] Fax: Email:[e-mail]
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.
Name: Camden Industrial,LLC
Address: P.O. 10440
City: Greenville State: South Carolina Zip: 29603
Telephone: [phone] Fax: Email:[e-mail]
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.
• Plan and conduct all land-disturbing activity so as to prevent off-site sedimentation.
201 E.Main St,5th Floor,Durham,N.C. 27701• [phone]• Fax[phone]
www.co.durham.nc.us/ceng

6. For business applicants,list below the North Carolina registered agent for the financially responsible entity:
Name:CT Corporation
Address: 2 Office Park Court,Suite 103
City:Columbia State: SC Zip: 29223
Telephone: [phone] Fax:N/A Email: [e-mail]
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.
10/12/23 G.Jackson Hughes,Jr.
Date Type or Print Name
864-233-0079 Manager
Telephone Fax 4keo:rptZtoAiliorjacksont�hughescommercial.comEmail tta
*************************************************************************•••• ************************.
Business Applicant(Provide corporate resolution on signatory authority)
I, Work 9►e( Z• melootvle. ,a Notary Public of the County of &reeenk{/1,� ,LC/,
State of 5OU(,�•Y 1 Ca�/()1,(• i ,hereby certify that S,A�•AAa,h.aU SOS L 1 3tnes 3r•
/Yl personally came before me this day and acknowledged that he is a i J
of CavanTaudlta L itland acknowledged,on behalf of Cofyiden Tr Ag r 4a t L�
,then due execution of the foregoing instrument.
n—
Witness my hand and official seal,this l day of C G�v`r ,20 1)--
_f
�
Notary Public .s.0. EY►X.
",,
N My commission expiresD�I-Th QC�" l2 ,20 �V • J •CARY P.B� �9 ,
*****************************************************************************************************************j*sip** + ,m
Individual Applicant :4 ' � o�
I, ,a Notary Public of the County of 't •_\ ,�`<L.
State of ,hereby certify that Ty.exp
CAR0;;,•`�°,
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.
10/12/23 G.Jackson Hughes.Jr.
Date Type or Print Name
864-233-0079 N/A Manager
Telephone Fax Title .� to i
j ackson1hughescommercial.com •
Email Y tut:
*******************************************,********************************** ***************************************************
Business Landowner(Provide corporate resolution on signatory authority)� 11C
I, �,Oi.k r1nel • Ma/Cal ' ,a Notary Public of the CO'ounty of 1`
State of j r 11•J ,hereby certify that va�Y1 hec Jr
personally
� came before�_ me this day^ and acknowledged V I that he is ✓ a�� -
of Ca) aal .fo I4t t v`C.4 1 "`V fi d acknowledged,on behalf of CAAMAC1A Yy 1au a.l 1/�
,the due execution of the foregoing instrument.
Witness my hand and official seal,this 2`1 day of QCil Yam' .20
rjrnviata--
,�,p��,, t _,, 1 Notary Public ��������******•*,,,
My commission expires NV Y 1 t 1 l� ,20 ,.�� � ,X *%t9 ,,
ts
**************************************************************************************************************.sbr2 PR�ot ��0 9_
rO; '.
Individual Landowner 'Uc !•" e
I, ,a Notary Public of the County of - �,:
State of ,hereby certify that MM• EX? 0���,
v � ,
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