NCC241636_FRO Submitted_20240530

DURHAM JCN
COUNTY Durham City/County (Office Use Only)
Sedimentation and Erosion Control
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
�Isa 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: Latta Park Commercial
2. Road location of land-disturbing activity: Guess Road & Latta Road, Durham, NC
0824-07-89-6643,0824-07-86-0145,0824-07-73-3764,
Tax Map- Block- Parcel: PIN: 0824-07-62-3340,0824-07-51-3296
3. Square footage of land to be disturbed or uncovered: 491,357 St
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners,please list on a separate page):
C4 Investments LLC
Name
121 W Trade Street, Ste. 2550
Address
Charlotte North Carolina 28202
City State Zip
[phone] [e-mail]
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.
C4 Investments LLC
Name
121 W Trade Street, Ste. 2550
Street Address
Charlotte North Carolina 28202
City State Zip
[phone] [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.
• 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., 1s` Floor, Durham,N.C.27701 •[phone]• Fax[phone]
www.dconc.gov/index.aspx?page=180

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.
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Date Type or Print Name
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Telephone Fax Titl ut • .-E •
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Business Landowner(Provide corporate resolution on signatory authority)
//
1, i S1 N /C1('j I fso P all 5 ,a Notary Public of the County of ti1(v/ t{u hJ ✓e
State of Vlcjt vt (urcli ftv- ,hereby certify that Mr" 141114 tM'l lief nt '
personally came before me this day and acknowledged that he is rV` i'lit (A7
of „t; I61VtT h4/1 �� C and acknowledged,on behalf of (Lf I��Vilyytel4 it L-LC
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..... 'f/ ,the due execution of the foregoing instrument.
�:' 0�e�S Clad af)d official seal,this c77� day of b�cc� / ,20 22
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Notary Pub c
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' �d6�isc?xpires Jii ,20
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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.10/13

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
C4 Investments LLC
Name
121 W Trade Street, Ste. 2550
Street Address
Charlotte North Carolina 28202
City State Zip
[phone] [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.
understand that the person or entity listed on Line 5 above will be: (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.
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Date Type or Print Name
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Telephone Fax Title utC h 'ty
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Email S• ature
Business Applicant(Provide corporate resolution on signatory authority)
I, VVIsSifo tit E tl 1'J'a.-Pall 0..f , a Notary Public of the County of fl I-1 el N 0 veY
State of 11 01/ [a i , hereby certify that Tel{'V1 L S A; h WI III 4 h1 S
per§pnally,came before me this day and acknowledged that he is AA a i ti
\\� �\\Sd�p 4.4 f,14voceIfT ( ( C and acknowledged,on behalf of CI-1 , yt 1 L4/J' CI C
• O •
z A R Ycf; ,the due execution of the foregoing instrument.
AVigleSS10/41" official seal,this tg-J— day of DerefN&, ,20 2 2
•
hgNp�R• ',�" Notary Pu'b1•
Myildiitiniission expires G� � ,20 24 .
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Individual Applicant
1, ,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