1. Revised 2/1/2011

2. Parts 1-4 are self-explanatory. The PIN number is obtainable through City Planning or on-line GIS maps. PLEASE TYPE OR PRINT 1. Project name:_______________________________________________________________________________ 2. Road location of land-disturbing activity:__________________________________________________________ Tax Map - Block - Parcel: __________­­­­________________________ PIN:­­­__________________________ 3. Square footage of land to be disturbed or uncovered:_________________________________________________ 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 ___________________________________________________________________________________________ Address ___________________________________________________________________________________________ CityStateZip ___________________________________________________________________________________________ TelephoneFax Email

3. Part V Identifies the Party agreeing to be FINANCIALLY responsible for assuring compliance with the Durham County erosion control ordinance. FRO responsibilities are shown on the next slide. 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 __________________________________________________________________________________ Street Address __________________________________________________________________________________ CityStateZip __________________________________________________________________________________ TelephoneFaxEmail

4. Legal Obligations of the Financially Responsible Party 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.

5. Registered Agent The registered agent is that party whose name is filed with the NC Secretary of State’s Office as the agent for the business filing as the financially responsible party. 6. For business applicants, list below the North Carolina registered agent for the financially responsible entity: _______________________________________________________________ Name _______________________________________________________________ Street Address _______________________________________________________________ CityStateZip _______________________________________________________________ TelephoneFax Email

6. Part 7 requires the Name and signature of either the individual applicant or, in the case of a business, the signature of an authorized representative of the business. The authorization must be supported by a corporate resolution or similar document. In addition, in either case above, the signatures must be notarized. The notarization segments are shown on the next two slides. 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. _______________________________________________________________________ DateType or Print Name _______________________________________________________________________ TelephoneFax Title or Authority _______________________________________________________________________ EmailSignature

7. Business Applicant Signature Business Applicant (Provide corporate resolution on signatory authority) I, _________________________________, a Notary Public of the County of _____________________________________ State of ____________________________, hereby certify that ________________________________________________ personally came before me this day and acknowledged that he is _____________________________________________ of ________________________________ and acknowledged, on behalf of ______________________________________ __________________________________, the due execution of the foregoing instrument. Witness my hand and official seal, this ____________________ day of _______________________, 20_______________ _____________________________________________ Notary Public My commission expires __________________________, 20______.

8. Individual Applicant Signature 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______

9. Part 8 must be completed by all affected land owners in the case of land disturbing activities being undertaken on land not owned by the permitted party, 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. _______________________________________________________________ DateType or Print Name _______________________________________________________________ TelephoneFaxTitle or Authority _______________________________________________________________ Email Signature