NCC222076_FRO Submitted_20220613

� i i ATd l A M C: Chi N-Y-Y
N t) it t k{ C A K ('f I INA
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: Mosaic @ Chatham Park - Phases 1 D & 2B DATE: 5/10/2022
ADDRESS OF PROJECT: 78 Mosaic Boulevard
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35 deg45'21"N; 79 deg 09'50"W
PARCEL #(S): 9753-00-00-9566 (0094079)
TOTAL DISTURBED ACRES., SQUARE FEET: 0.45 Acres
PURPOSE OF ACTIVITY: Construction of Building G
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: Eco Mosaic, LLC Phone: [phone]
Address: 603 Carthage Street, Suite 120 E-Mail: [e-mail]
Sanford, NC 27330 Signature:
**FINANCIALLY RESPONSIBLE PARTY (applicable onlv if different from nronertvowner
Name: Eco CP Partners, LLC Phone: [phone]
Address: 603 Carthage Street, Suite 120 E-Mail. [e-mail]
Sanford, NC 27330 Signatu
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
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: [e-mail]
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Jody Leidolf
Company Name: Montgomery Development
Phone: [phone]
E-Mail: [e-mail]
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—'`— Soil Erosion and Sedimentation Control
CHATHtvt A " 1 1 -4r-
V
N C1 - t i/ t n R f1 1 1 Financial Responsibility/Ownership Form
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. 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.
OWNER OF PROPERTY:
Name and Title: Kirk Bradley, Manager
Company (if applicable : Eco Mosaic, LLC
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title: Kirk Bradley, Manager
Company: Eco CP Partners, LLC
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
1
I, Y , a Notary Public of County in the state
of N do hereby certify that ' V iL personally
appeared before me this day and under oath acknowledged reading the information abo e and acknowledged that the
above form was executed by him or her.
Witness my hand and official seal, this theday of.��� 20a.
Notary Public Na A Ply
My commission expires 1, ty o� 3 No"hC
ri c t�mission Ex fires a
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