NCC221850_FRO Submitted_20220516

Land -Disturbing
Permit Application
**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: Northwood MUPD - Lowes Foods (#274) DATE: 06/22/2020
ADDRESS OF PROJECT: 2429 US Highway 15/501 Pittsboro, NC
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35d 45' 18" N; 79d 10' 01" W
PARCEL #(S): 006723 (9742-00-99-1594)
TOTAL DISTURBED ACRES or SQUARE FEET: 6.57 acres
PURPOSE OF ACTIVITY: Construction of grocery store, retail building and fuel center
FEE AMOUNT SUBMITTED: Cov. under Northwood &4UPD
**LANDOWNERS 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: 15/501 West, LLC Phone: [phone]
Address: PO Box 3557 E-Mail: [e-mail] 42
Cary, NC 27519 Signature:
**FINANCIALLY RESPONSIBLE PARTY (apRlicable only if different from property owner
Name: MDI Management, LLC - Shawn Beichler Phone: [phone]
Address: 120 4th St. SW E-Mail: [e-mail]
Hickory, NC 28602 Signature:
N OW —
NORTH CAR LIMA AGENT (applivable on y if owner or financi a I ly res ponsible party does not reside in
North Caroling
Name: _ Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR
Company Name: CE Group, Inc.
Address: 301 Glenwood Avenue, Suite 220
Raleigh, NC 27603
Contact Person: Mitch Craig, PE
Phone: [phone], Ext. 108
E-Mail: Mitch@CEGroupinc,com
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Shawn Beichler
Company Name: MDI Management, LLC
Phone: [phone]
E-Mail: [e-mail]
Page 2 of 3

Soil Erosion and Sedimentation Control
C. FfA"1 FiA1VY C(7lIN"I"Y Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT 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 from the date of issuance. If circumstances warrant, the permit 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. If 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 civil 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 true 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 and
accompanied by a complete list of all partners, managing members and registered agents of the company or corporation.
OWNER OF PROPERTY:
Name and Title: Tim Smith Vice President
Company (if applicable): 15/501 West, LLC
Signature:
TIONAL FINANCIAL'
Name an
Company:
Signature:
NORTH CAROLINA AGENT (if
Name and Title: —.00000
Company:
SPONSIBLE PARTY (if any):
I*��*�*�kk***%k**�k�=k�k*�k**�k*�hk*II,�k
I V4QM4 a Notary Public of ��V� ��`f� County in the state
of do hereby certify that_personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her. ]�
Wit ss my hand and official seal, this the day of. ��n , _ .2016
1
Notary Public V, ALAMy commission expiresAp,2023
�Ca 0qL}RJl-�
pU6�-\� ;
Page 3 of 3 .I *A

� Soil Erosion and Sedimentation Control
Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I ) This section must be signed in the presence of a Notary
2) All Land -Disturbing permits are valid for up to (2) years from the date of issuance. If circumstances warrant, the permit may be
extended for (2) years per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Upon written
notice, the Land -Disturbing permit may be revoked for failure to comply with the Ordinance. If 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 civil 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 $5000.00 per violation
per day and is assessed daily for every day the property is in violation. Interfering with or hampering an inspection can result in a civil
penalty without written notice.
3) The information provided on this form is true and correct to the best of my knowledge and belief and was provided by me while
under oath.
4) This form must be signed by the property owner if an individual. If owned by a company or corporation, this form must be signed
by an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the corporation and
accompanied by a complete list of all partners, managing members and registered agents of the company or corporation.
O Y:
Name and Title:
Company (if applicable):
Signature
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any): Name and Title; Shawn Beichler. P*@&kWfft try rr'jJ CYICC.Aaeerl Y P Ate �$
Company: MDI Management, L C.
Signature:
LINA AGENT (if any):
Name and Title:
Company:
Signature: _
l,thlL1.I . a Notary Public of r� D 2 County in the state
of (5 lfrzL, o hereby certify that- 5hown Itich ie __• personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her
Witness my hand and official seal, this the c2A day oD une . 20-Qb.
Notary Public SltitleyH.Smrth
Y p � c) {SEAL NOTARY PUBLIC
M commission expires ) Davie, NC
yj Comminim Expires March 27, 2021
Page 3 of 3

., t! 1 t 0 t .. .l . f
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
utuav., 111%, UUGu wnci1 \.a lGul atlili:. UISIUCUGU alud.
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 Requirements:
Desi n 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
web a e. This plan must satisf 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 drainagepattern(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:
$100 flat fee
Plan Requirements:
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