NCC216184_FRO Submitted_20211108

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N l7 It 7 H C' A R" I. I N A
Land -Disturbing
Permit Application
Please complete both pages of this form and return to: For Office Use:
Physical Address Mailing Address
80 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, 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:
Permit Fee: $250/disturbed acre
Plan 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 Plan: 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 construction details.
These can be found on the Chatham County Watershed Protection website, on the Erosion Control
webpage. This plan must satisfy all local, state, and federal minimum plan requirements.
General Plan: 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
lot drainage pattern(s) on sheet 1 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 RESPONSIBILITY/OWNERSHIP FORM"
not required.
Fee Requirements:
Plan Requirements:
$100 flat fee
Site Plan showing property boundaries. The site plan required by the
Environmental Health or Central Permitting Departments is sufficient.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

1r--1
Land -Disturbing
CI t. k I i C- Cc7- it N A Y Permit Application
�i c)It � �i c-� unc-rNA
**The mailing and street address of the principal place of business for the person/entity financially responsible and
the land owner(s) must be provided. A P.O. box is NOT acceptable as an address.
**If the financially responsible person/party is different from the current land owner, an agreement signed by both
parties must be provided allowing the financially responsible party person to conduct the land -disturbing activity on
the property.
PROJECT NAME: Westfall Lot 101
DATE: 7/27/21
ADDRESS OF PROJECT: 277 West Beech Slope Ct., Chapel Hill, NC 27517
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.8252/-79.0572
PARCEL #(S): 93545
TOTAL DISTURBED ACRES or SQUARE FEET: 0.40
PURPOSE OF ACTIVITY: New SFD
FEE AMOUNT SUBMITTED: $500.00
"LANDOWNER(S) OF RECORD (attach page to list additional owners)
Please provide a complete list of partners, managing members and registered agents if the responsible entity or
land owner is a group of individuals, corporate organization or entity.
Name: Westfall Associates Phone: [phone]
Address: 128 Yorkchester Way E-Mail: [e-mail]
Raleigh, NC 27615 Jan Futrell Digitally 7.27 an Futrell
g Signature: Date: 2021.07.27 14:44:05-04'00'
"FINANCIALLY RESPONSIBLE PARTY (qpplicable only if different from property owner)
Name: ICG Homes, LLC Phone: [phone]
Address: 4020 Wake Forest Rd. Ste. 306 E-Mail: [e-mail]
erry
Raleigh, NC 27609 g Ryan Perry Daietal2021.07.277ned y14.44.Ryan 7 -04'00'
g Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Taylor Land Consultants, PLLC
Address: 1600 Olive Chapel Rd. Suite 140
Apex, NC 27502
Contact Person: Jeremy Taylor
Phone: [phone]
E-Mail: [e-mail]
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Ryan Perry
Company Name: ICG Homes, LLC
Phone: [phone]
E-Mail: [e-mail]
Page 2 of 3

C'II I I11AN't C;( )11-%t
Soil Erosion and Sedimentation Control
Financial Responsibilite•/Oi� nership Form
N0T1?A;0(II111:1) 1U) Bj; ('U:1J!'1l)1•'UI?
PLEASE READ THE FOLLOWING INFOMMATiW
I ) This section must be signed in 111C presence of a Notan
i All Land-Distnfiing permits are valid for up to (?) Nears from file dale of issuance. If circumstances %arrant. tlae permit may be
extended for (2) scars per file corxiitions of the Chatlann Cotnatc Soil Erosion and Sedimentation Control Ordinance. Uponxrriticn
notice. the Land-Dislurbing permit may be revoked for failure to comph N ith the Orditutnce. (f the permit is revokcd. all other
pemuts and approNals are aitlihcld until the propem is once main in compliance faith Chatham CouutN regulations. Also. upon
x%ritteta notice. it ciN it penalh (fine) can be instigated against the propem 0%%ner and/or additiomil linanciall) responsible parr (if am )
for iolations of the C'halhana COntalN Soil Erosion and Sedimentation Control Ordinance. This peiaiallN is tap to 'i0 oo.00 per \ iolation
per da} and is assessed daily for everN da% the proper(\- is in violation. Interfering \\ ith or hampering an inspection can result in a cis it
pcnaltN \1 ithout «ritien notice.
a Tile infonnafion provided on this fonn is inre and correct to the best of nn knowledge and belief and was provided b\ nee Nchile
under oath.
4 ) This forni must be signed b� the propcal\ 0\Cner if an indi\ idu al. If oi\ ned b\ a conlpam or corporation. this form must be signed
b\ an officer. director. partner. attorney -in -fact, or other person midi authorih to execute instnunents for the corporation and
accompanied b} a complete list of all parlr><rs, managing members and registered agents of the compam orcorpomtion.
OWNER OF PROPERTY:
Name and Title Jan Futrell, Manager
Conapan\ (ifa )licablc) Westfall Associates
ture:
Signaa , / ----- —
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (ifany):
Name and Titl, Ryan Perry, Owner
Compam : ICG Homes, LLC
Signature
NORTH CAROLINA AGENT (ifaii ):
Name and Title:
Company:
Sig,nature
1 Holly W. Brazell
North Carolina
a Notan Public of Wake
- cOlmtVni tl1C StaIC
hereby certiA- that Jan Futrell personally
appeared before me this day and under oath acknowledged reading the infornaation aboNc and acknrn,Ird�=cd that the
abocc form \\as e%ccutcd b\ him or her. „�„�,,,,.,,,,,,,,.
27th Jul W • BR'' ��'itn.,� nn hand and official seal. this the da, of y 2021 s�'��l
��, .................
Nc�tar� Puh i;: -
\1, commission c\hires 08/21/21 ,, C, '•V
"Z,.,COUN�,��'`

Soil Erosion and Sedimentation Control
Financial Responsibility/ON` nership Form
V'0%'Il/•;O1 '11U..)
PLEASE READ THE FOLLMVi\Ci I\FORMATION:
I ) This sect roll Inust be signed in I11C presence of it NolarN
�) All Larxi-Disturbing permits arc Valid for up to (2) tears from file date of issuance. If circumstances iurrtnt. the permit maN be
extended for (2) Nears per the conditions of the Challtalln CounIN Soil Erosion and Sedimentation Control Ordinance. Uponnritten
notice. file Land -Disturbing permit maN be rooked for failure to comply with the Ordil>iulce. If the permit is reNokcd. all other
permits and approvals are %aithllcld until the properiN is once agilin in conlpliallcc "ith C11Mharu County reg w ritten notice. a ciN it penalt} (fine) can be instigated against the propene owner and/or additional linanciall\ responsible tms(ifulpon
for violations of the C'halham County Soil Erosion mid Sedimentation Control Ordinance. This pcnalt� is up to auu.ru► per iolation
per da} slid is assessed daily for e\en &a the properlc is in Violation Inlerfcring kith or hampering an inspection can result in a civil
pcnall� I%ithoul X%rinen notice.
I) The information pro\ ided on this form is Ime and correct to file best of nn kno\\ ledge and belief and mas provided be the while
tinder oath.
4) This form must be signed b% the proper\ 01%tier if an indh idual. If o%\ tied b% a conlpam or corporation. this form must be signed
by an officer, director, partner. attortle\-in-tact. or other person kith aut}lorih to execute instruments for the corporation Illd
accompanied b} a complete list of all partners. nuanagim members and registered agents of the conlpam orcorporltion.
OWNER OF PROPERTY:
Name and Title: Jan Futrell, Manager
Compam (if applicable) Westfall Associates
Signature
ADDITIONAL FINAN('IAL.LY RESPONSIBLE PART) (ifany):
Name and Title Ryan Perry, Owner
C
NORTH CAROLINA AGENT (if an-v):
Name and Title.
Company
Signature:
I Holly W. Brazell
of North Carolina
Wake
Count\ in the state
�rsonallv
appeared before me this day and under oath acknowledged reading the information above and ackno\x lcdlocd thatthe
abo\ e form \Na: � \Qcuted b\ him or her.
_. a Notary Public
do hereb, certifi tl
Wimcss m\ hand and official seal. this the 27t ' da`. of July
Notary 13116
u i
M-% commission expires 08/21/21
Ryan Perry
2021 °'�- W . 81Z "'°,,,
=rs�
(SEAL) "%-qAU 8,..
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