NCC223258_FRO Submitted (6)_20220916

Land -Disturbing
ClEI NVII IA M CQUN-Fy -Permit A pplica ti f)n
+rCiN7:" L Anrt1 • � k
I'Icaw vmnplrtc both pages of this farm and return For Of f'
Physical Address Mai I ing Adds s
:90 Fact Si- I'D Box 548
Pittihoro, NC 73 t2 P- fihoro, TIC 27312
Phone- (919) 5 -9268
Irlcaw T'F RN rTTNG FLOW CHANT to dctcrm Me Which p rmil and pwm rmqul remerss ably to
.•.Dur project and there check unre of the boxes below,
0 I and-Distu r$iag Permit, The kollcwing itrms afe required to obtain this permit- coo pletcd
appficatKin, plans_ and firms, Land -Disturbing ?C mit applications MLm include all PM*CWI0U Im
one appl iLatic a with the total aFpouniL of distmbanoe for all pw vzVI rats_ f's.11 cli�sri ng anal disturbance
roust be included w1ken oul tip di rb aV
rrte R-eguirrFnenls;
Permit Fee: $250/0 i.turbed acre+ _
13'Jan R-�vie%v U eye: 0fdislurbed acre
Fees are rounjtcd up to the next whOlc 9c.ru_
_xampl�- I a� or less iw $600, 1.Ol-2 acres is I.0004 and 2`01-3 is $15M
Plan R ui reme' ► S-.
Deep Plan- submit (l.) copy of an cr05i4xn uontrol plan c twnpleted ,ruled by a profc: ionaJ land
surveyor, prt3reSSional engineer, or rcgiswred landsc urc€iitect. This plan must mr�Oi the criteria of the
(-[rutharn C..4purrty Erosion Cr ntrol 111m Rm iew C heckli w1 arvd include all app] icablc (xynst.ruction dctail�;.
These can be J bund on thy: Chatarn County Waiershcd Pro ion wchsilc, on the Ems-lun C.011tro]
web a c. This plan must sat;9i y aI i local. 1 ait, rind fedcraa midi rnum plea xqu i remerm.
Cencr� l'I$�: subm it 0) copy Of �it� pLan along with the Chatham (aunty l; iderrtial [ ncral plan. Site
plan is not required to Yee om-nplc" by a desiga proft- iorral, ihf� Residential Ocmera1 Tian can be I ound
on tyre C luitham County Watcrsfimi Protection wwbsde on tk R"'Riticntial Construction %-ebpago_ I ud le- ate
logy na,ge patterns) on shcGl 1 of&e KoidQntial [irencral Plan- _ --
❑ R"identisil ][mot PgrmiC_ Thu foll0 inc items are requkcd t) obtain this prwmit, complehtd
appli�,urr, she plan, and fee. f AGF 3 `T I NANCTA L RLSPON S IR I I.I'I-Y?OWN FR.I L LI' FORNT'
not rc uircd-
Fee 1~t uirwir= Pl:Arr 9 Uircm-rrits; -
100 flat fee S itc Fly showing p operty haundiadc!s- T3�e site plan rr-quirad by the
Envimnrtrental Ii al th c C errEral 'Tmlttl �
_# pcp rjments its suffix it ,t_
ALL U1EC KS MADE PAYABLE I'D CI ATHAM { U JNl'Y
Rage 1of3

Lsn d-Disturbin g
M �� „ �Q. J. I N Permit Application
11*The mailing 2Lnd slrml gddreas of the })rPH-CiP31 plain of hQ%+ncm for Ike. Pee Ram'V alil}' fi Fin nw i:afly respon qi File and
the land •ner(s) m u4i be provided, A R0. box is NOT 100ept3ble As an arEdTQ%.&
'� If the Gnartrtilf resp�rnsi perm rparty is dif#ercnt JCx ern tie cu rrt al ]:4 n d tamer. #i4raem ant sir;ue[l h h��ih
pSrtirs muSl prm�i�i All winz t he ![jKjm jxI ly responsible part} pbC &n to c��ndusL the Esnd-iis turbiikg actiti ili uo
the Pruperty_
PROJE1�=T NAME: T� i 37 DATE: aag
ADDRES.'i OF CD?CT: 77 Huh Rid9� !! lMtFom, NC 2731:2 —
Ft,ATl'I'UDEf LA)N('- U UDE OF PROPERTY AT SFM ENTRA NCE. f -7!9??2
pARCIF.1, #(6;): B14
TOTAL DISTLRBED Af,'RES orSQUAR . MET: 0_3 2rar.Yes —
PIJRPOSF. OF AC'T V]TY: nuw SF.D
FEE AMOUNT SUBM FT ECk-. _
**1;1 N L7 y4'NC F R atLach Vapw ����.�y
Please provide a comply list of partners, managing rnmlbm and registcrw agrftts if the
r��i]S1�IC �nLit�+ car
land owar r is a goup {rf individuals, coToram crganizatioa or errrity_
Tame- ThplEbA Homey phoae; t2
_ f
Addr - PO BLix 1117 _ I: ,+idll; kauf9@hlplgah ear
Rally Spftgs,14C 27&W Signature: _
DINSIR11 PAW1 Y 4321 icable Only i f di Ihermt fnim prMeM owner
N me_ Phon°:
Address' E-Maii-
NORTH �ARQLT N
I=aroE"
Addres .
A G I -,N-1' (awI Wable on iy i lr Qwner or finanrial I y r nsibjr, ELrrw doe - AQL reside in
Company Name: Rnside!Nm LEM a!�, PLt_G
Addi'eslq- 1W Evans Ind
Cary, NIrt 2752
Cxirtact PM-m: Dean Fed -as
Phone~ 919'�39 l —
FMOSION. MNFR L
PerjiOlk to avntaLll slkon}d-CMNiOn .fie sedinvent
cqm trr l issues arises during Jonrl-digturbi.n9 ar.#i -AY}
canmcr Peres: Davd Dal
Company Name- Triple A Homes
PtMnc- 91 fi`:2TOA928
F,M,H: david@b iok- Wes-Drg
Page 2of3

Snit Fru�,ion and Sedimtkita#io n Coatrol
J'i nan-cia L Respo n n enhip Form
V0r.Rr5!L) 1J1 To BE �'_ OMP ET'EV FOR RE& 71,41, 107 - PERK
PLEASE Rl,"A O THE FOLLOW INU I NF T I ON!
1)'INSaccdon muxL bL 9ignCd lat1r, Pitwnmof$NCUXj'
2) All LaPW-DjstkH?10! perinits are Valid for kip to (2) yem rr� mi 11w datc cf Ef ar=smn M -y- rail, ncc Pcnnit TMY hr
.rxtrndLtd for (2) }-cars per d-te conditions oC tha Cd2han7 CCIn►ty i I F.Mf.ion artd 5ediMWLWiM COMA A 00iFMriuC_ l,p n Wfam
ruitim the Lard- I ]ixiurNrlg paIIrlt may 1t CC-.roLM for Gl1113re to CZWWL}• with the (WirEnM If Ide perrnit i5 Tvn ktxJ, a19 ntlrer
pwrriLN mwJ approvals art.-v.irhhcld until the Llr47&Tty is oncc apin in c4.wnpleaz= with C.hAthaln ['Jaunpy re.6 plaklolkx. Alga- l
Wriitrn aMi47G. x eik II f+ellalty (ji") C M 3 he ifLs �a" �in%L dtc pf0Pol y CnAm er wxUvr addi[ Lm1 frr,anciail}' y DnsiI �xiriy {7�MF�
for vioIaticqs afthe CtulIIarn CMULY Soil Ewsic�u aisd SodirlreaUiun (=,aIy" Ordinw-r.e. 'L'Iu:.. pemIty is up U5 !�5WD-0.}' per Vi4DIPtrrm
Mr day and is air m!d daily tier cvM day the P ay ti'inlxRlrxn. ]nterftxin with ar hamp rinr- Z+L IM9P �tion C-M r44V1t IM t ch
3) Tlv.-inforrrtwn pTavided on thix Pcmn is L= Bad 4P r L i o Ube ben cfmy knimled&P aM bdivfmuL vi$R provided by me vrhilc
under oetm
4) '1•his fnrm must ho sib by Lhc prapa ty our i f itldi5redunL lrtrywr by $ caariperr+ c,+r rfaratioru this F{,rrri most be skmed
by an ojficCT, +iirw-mr, pmuzr, inLtc n%y-i o-fam air othcr peMM with aLFLI"Ly m cv.ozule inslaurriax for the cogporaLi4nh azud
aomWamed by a oompIctc List ufAiI parvcrs, managmgTwrabem and rekoslered agents oftbeccym pany oQ arrporaticm
Name and'fidh. Dar? � . Pm!5id
Tlt
ADDY110NAis F]NAN ALLY RL*,,'PONS)FRLE. PAWrY Cifsny):
Nsmt aad Title:
.Omgany_
S ignawre=
NORTH CA ROLINA AGRN'r (if any)-
N=u slid Titlo:
ctim lly,
Sio&urr;
wL, Pam' , a rti Mary Publ is c& + e' County in tiix. Mic
cwf• Afar d-a horoby L:erLit' that 594q, �' p rs ,7al3k
appeared biro mt: Lhis day and undm c, dJ. ad-.nr1wl0i Ttzdieg the intbrmatiuu ;ab0 . and aCknKYW1bd ed thatthe
above form was "jbffatr_d by him or her.
w ibun!, my h=d prod u icial this the 4 d *' of "tk_
I r • —
Natary Public.
My c.offm issic n o+cnirrs
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