NCC223012_FRO Submitted_20220826

Land -Disturbing
Permit Application
(Please complete both pages of this 'Bonn and return to: For Office Ilse_
Physical Address Mailing Address
go East St. PO Box 548
Pittsboro, NC 27312 Pittsboro, NC 27312
Phone: [phone]
Please see PERMITTING FLOW CHART to determine which permit and plan requirements apply to
your project and then check one of the boxes below:
❑ Land -Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, deed, and fees. Land -Disturbing Permit applications must include all parcels/
lots on one application with the total amount of disturbance for all parcel/lots. All clearing and
disturbance must be included when calculating disturbed area.
Fee Requirements: ----- — — --- I
Permit Fee: $2_50/disturbed acre - --- — - �
lan Review Fee: $250/disturbed acre -
Fees are rounded up to the next whole acre.
Example: 1 acre or less is $500, 1.01-2 acres is $1,000, and 2.01-3 is $1,500.
Plan
Design: submit (1) copy of an erosion control plan completed & sealed by a professional land
surveyor, professional engineer, or registered landscape architect. This plan must meet the criteria of the
Chatham County Erosion Control Plan Review Checklist and include all applicable constriction details_
These can be found on the Chatham County Watershed Protection website, on the Erosion Control
webpage. This plan niust satisf--, all local, state, and federal minimum plan requirements_
General Plano submit (1) copy of site plan along with the Chatham County Residential General Plan. Site
plan is not required to be completed by a design professional. The Residential General Plan can be found
on the Chatham County Watershed Protection website on the Residential Construction webpage_ indicate
Plan -
lot drainage patterns) on sheet l of the Residential General Plan_ _
❑ residential Lot Permit. The following items are required to obtain this permit: completed
application, site plan, and fee. PAGE 3 "FINANCIAL RESPONSfBILI`fY/OWNERSHIP FORM"
not -�: ,uired.
Fee Re c nircrnents: Plan Requiremr!nts.
$100 flat fee
Site Plan showing property boundaries. The site plan required by the
Environmental Health or Central Permitting DeParinents is sufficient -
ALL CHECKS MADE PAYABLE TO C:HATHAM COUNTY
Page 1 of 3

Land-Distu bin, 6a
Permit AppUca on
"The mailing and street address of the principal place of business for the personlentity-fingncially responsible and
the land owner(s) must be provided. A P.O. box is NOT acceptable as an address.
'r*lf the fimncially responsible perion/party is different from the current land owner, an agreement signed by both
par i!es must be provided aflowing the financially responsible party person to conduct flee land-clisttarbiag activity on
the property.
PROJECT NAME: Villar Residence Lot 38SC
DATE: 5/30/2022
ADDRESS O! �J1L.F PROJECT: 163 Ket�woodLane, Pittsboro NC 27312
LA'�`A`l'CJ llJiJVj'ILONGI E OF PROPERTY
g AT SITE ENTRANCE: 35.842f28614948635,-79.14918151fl02304
PARCEL #(S): 93971
TOTAL ®r9.STl1RBED ACRES or SQUARE FEET: 3 3 5- IF
PTIRPOSE OF ACTngTY: SFD
FEE AMOUNT SUBMITTED: -
"LANDOWNER(S) OF RECORD (attach page to list additional owners) p„t,�, co K�
Please provide a complete list of partners, managing members and registered agents if the responsible entity on
land owner is a group of individuals, corporate organization or entity.
Name- John Villar and Jennifer Lachman Villar Phone: [phone]
Address: 714 N. Henry Street, Alexandria VA 22314 E_Mail: [e-mail]
**FMANE
John
Name: Hnm
PARTY
Address: 1297 Chatham Church Road, Moncure NC 27559
AGENT
North Carolinal
Name.
Address:
ENGMER/SURVEYOR
Company blame: Lester Stancil and Associates, PLS
Address: PO Box 730, 98 E. Depot Street Angier, NC 27501
Contact Person: tester Stancil
phone: [phone]
E-Mail. [e-mail]
Signature:
Phone: [phone]
E-Mail: *[e-mail]-
xner or financially responsible narty rives i
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Phone.
E-Mail:
SignatureF-ONT
EROS1OROL
Person to contact should erosion & sediment
control issues arise durinc, [and-disfurbing activity;
Contact Person: Joe Kelly
Company Narue: Kelly's [forth Carolina
Phone. [phone]
E-Mail: Kellync.offce@gmail_com
Page 2 of 3

` 'Sall Erosion and Sedimentation Control
EA XI C-a_)fii,-� r Y Financial Res ponsibfty/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL. L.OT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
1) This section must be signed in the presence of a Notary
2) All Land -Disturbing permits are valid for up to (2) years fi•om the date of issuance. If circumstances warrant, the perTnit may be
extended for (2) years per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Uponwritten
notice, the Land -Disturbing permit may be revoked for failure to comply with the Ordinance. It the permit is revoked, all other
permits and approvals are withheld until the property is once again in compliance with Chatham County regulations. Also, upon
written notice, a civi r penalty (fine) can be instigated against the property owner and/or additional financially responsible party (if any)
for violations of the Chatham County Soil Erosion. and Sedimentation Control Ordinance_ This penalty is up to $5000.00 per violation
per day and is assessed daily for every day the property is in violation. interfering with or hampering an inspection can result in a civil
penalty without written notice.
3) The information provided on this form is tine and correct to the best of my knowledge and belief and was provided by me while
under oath_
4) This form must be signed by the property owner if an individual. If owned by a company or corporation, this form must be signed
by an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the corporation
accompanied by a complete list of all partners, managing members and registered agents of the company or corporation.
vio
OWNER OF PROPERTY:In-
Name and Title: JohnVil€ar, and Jennifer Lachman Villar-.vXptRyt
Company (if applicable):
Signature:
�1'i f�,+,i E
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any,:
Name and Title: John M Dunning
Company: Homef,pnt Buildo inc. dba Dunning Custom Homes
Signature:
NORTH CAROLINA AGENT Of any)e
Name and Title:
Company:
Signature:
t r, p n a Notary Public of Co-unty in the state
of � do hereby certify that �Y�n �� '► .r�� personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe
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above form was executed by him or her. �p
°o� yea
Witness my hared and official seal, this the___ day of : ne o°�°� °o
_ moo& a
Notary Public
My commission expiresq
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