NCC223973_FRO Submitted_20221130

Soil t'l-osiou w] Seth etitation Control
ry .. + e e. ,. a e ♦ Finar>tcial Rc,,I)))ttsil)ilit�,/OAviiersliii) Ft)1"m
NOT 1c'EQ(' RED r0flE C-0,111'1 ETLD T Oft REsIL)ENTIA LOT PER..-waS.
}'[ t'' 1S lt_l wil) I l lI _1 t7i t.f)1?�INCa 11 1 C):I tr1't'3� 14
1) Ivis secuon must W smncd in the• presence "a Notary.
t AR t WDistwhirrg p.nwN me valid lot up to (2) years fiom the date of isswrnen tf cimummanacs warrant, the penrrit may be
cm.d d it t`a Taus per the: conditions of the t_hat.hatts Warty Sod W"On and Sedirtrcntmivn 01r€tr<A {7rdrn— UPmwrt wn
nort:'e'. the. Laud t.)r,twhine peranit may be retokcd fiat failure to comply with the Ordinance, If the permit is, revoked, all wFier
lwnnily :and q lama%, me w0hlrelef until dw paTerly is once WIP, in cornpliattce with Chatham Counly regulations, r' ko upon
unnn n now o a ci"' penalty (titre) can be instyawd against the property owner anit'or additional financially responsible partw hf arny)
for �iolainotasofehe (°h:athasn (.'crtsnty Soil t.rasion and Secfiirnentmwn Control t)rchrtance. This lwnahy is up to S5000 (0) Per Wealmill
per d'i-, and is assse-'xd daily AT evcqF day the propeny is in violation, lrtterferinz with or hamperingan inspection can result in a civil
pcnalty avrthout Nw lillen n.rasec.
3) Ile Arf anuauon provided one this fonts is true and correct to the best of my knowledge and belief and was provided by me while
Under OWN
A) This fonts must be signed by the property owner ifan individual, lt'owned by j cixnpany or corporation, this form must be signed by
an officer, director, partner, zanontey-in-fact, or' other person with authorily to execute instruments fear the corporatittu and
accontlainicd by a complete list ot'all parnners, managin' members stir(] registered agents ofthe rotrtpany orcorporation.
} This forth rtrust alser he sitinz zi by ilte iinancr;ril} responsible party and lit' tgetu (If,applicable)Same provisions of 0 4 above. apply,
OWNER OF PROPERTY:
N arise .and Title: Samantha R Hilton, Michael R Hilton
Company (it apes-t�c<ble): _
Signature:
FINANCIA1 C Y RESPONtill3LE P:iltTY (applicable only if different from property tnvner);
Company;
Signature:
NORTH CAROTJNA AGENT (if any)-
Michael T rrell
Name seed "Title,e..-_.........�_—�_,M��G.........__....
Company
Signature
}
I. j a Notary Public ot,._.._�� 4;� �{ County in the state
.
of f, : t . K & A do hereby certify that fy ?A Dc"O tally
appeared before me this day and under mh acknowledged reading the information above and acknowledged that the
above font �v as executed d by hint or, leer,
ha Witness ' w.. _ _._.stay of .X :x: R._E:_ ?'il_
er(± tart" rt and taf"fica ll seal, this tllct
rf ,�
�it:?Ittt k t}itl:':I§
My conunisNionexpfres......... .......... (SEAL)
ALICIA W. AL,
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