NCC231862_FRO Submitted_20230614

https://chathamcountync.viewpointcloud.com/categories/1082
Land-Disturbing
C'IIA"1"11 Ni .'l )1IN11
"" ' Permit Application
Please include all required signatures. 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, plan,and fee requirements
app y 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, deed, and fees. All clearing and disturbance must be included when calculating
disturbed area,
Fee Requirements:
See attached PERMITTING FLOW CHART
For fees that 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:
Design Plan: submit (I) 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 •lan must satisfy all local, state, and federal minimum plan requirements.
General Plan: submit (1) copy of site plan showing proposed disturbance limits 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,
Residential Land-Disturbin: Permit wcbpage. Complete table on sheet 1 of Residential General Plan.
® Residential Lot Permit, 1'he 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 and proposed disturbance limits. The site
!flint required by the Environmental Health Department can be used as a base.
ALE.CHECKS MADE PAYABLE TO CHA'I'HAM COUNTY
Page 1 of 3

C'd i A TI i;.\.N1 c'c ►I IN0 1 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 to conduct the land-disturbing activity on the
property.
PROJECT NAME: enwnod-!-inmes_ChanetAidge!gt 9 i3 L - DATE: __ iyl',I�,13
ADDRESS OF PROJECT: 53 S-4414.G1 /'11 C t-pdi,�, �& I
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 3C 71(367`-79 .2.200
PARCEL#(S): 61.7
TOTAL DISTURBED ACRES or SQUARE FEET: c, 4,4
PURPOSE OF ACTIVITY: Build New Residential Home
FEE AMOUNT SUBMITTED: $100 RIVER BASIN: CAPE FEAR
**L.ANDOVI/NER(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' _6i20ds Holdings LLC - Phone: [phone]
Addreswfici y f.uase krrainii NC 9761./ _- E-Mail: [e-mail]
Signature: -
**FINANCIALLY RESPONSII;I.l PAR l'Y (applicable only if different from property owner)
Name: -- — Phone:
Address E-Mail:
Signature:
NORTH CAROLINA AGj N'l (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Phone:
Address: E-Mail: - —
ENGINEER/SURVEYOR EROSION CONTROL
Company Name:Relidstntial Land Serv!ces?Lt.c Person to contact should erosion & sediment
Address: _jl t7-Evans_fld.-Gary_Nc2z513 control issues arise during land-disturbing activity:
Contact Person: r:had Knaplk_
Contact Person: Nan Rhodes Company Name: Glenwood Homes
Phone: [phone] Phone:
E-Mail: dear isnc E-Mai lcnactVgien saudhome carn....
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ANTICIPATED START DATE: 7/1/23 ANTICPATED END DATE: 6/31/24

Jam' Soil Erosion and Sedimentation Control
(.1rA.IIbleat Col IN I
` II Si
' " ' """ " ' Financial Responsibility/Ownership Form
NOT REQ111RA'1) 70 BE C'OMP1,1717)hOR R101DIsN77A1, LO)TPE7?N117S
PLEASE REAI)THE FOLLOWING INFORMATION:
1)This section must be signed in the presence of a Notary
2)All Land-Disturbing permits are valid Iiar up Io (2) years from the date of issuance. If cireunasuntces a:urnu. the permit mad he
extended for (2) years per the conditions of the Chatham County Soil hioston and Sctilintcttuttion Control t hdinuace. Iipun t%riuen
notice. the I,nnd-Disturbing permit may he revoked for failure to euntph taut the Ordinance. If the Itcrnat is revoked. all other
penults and approvals arc withheld until the property is once again in compliance with Chatham County regulations. Also.upon
ttriIten notice,a civil Itennity(time)can he instigated against the property ouncrand/or additional liunnciallr responsible patty(ifan )
lie violations'tithe Chatham County.Soil Ero>:iun and Sedimentation Control Ordinance.This penult•is up to$3000.00 pet violation
per day and is assessed daily for even''day the property is in vioiatuut. Interfi:ring o ith or hampering an inspection can result in a cavil
l)enalt without ttritten notice.
3)The inIbrnuttion prowled on this Barra is true and correct to the best of my knnttledge and belie I'and as provided by me while
under oath,
.11 This alarm must be signed by the properly ottncr il'an indit Ritual II'otylied by a etrmpunv oreoiporahon,this lunn must be signed
fit an officer. director, partner, attorney•in-liicl, or other person with authority to execute instruments for (he eorporalion and
.1t•campcnued by a complete list ol'all partners,managing members,and registered agents of the conipam'oreorporation.
OWNER OF PROPERTY:
Name and Title: Edwin Woods Manaqinq Member
Company (if applicnI Jc4: Woods Moldings LLC _
Sigt►ntutc;, t<ZD
ADI)I'I'I�L FINANCIALLY RE
SPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature
NORTH CAROLINA AGENT(if a rty):
Name and Title:
Company: -
Signature: - — -- —
*etc****:kek*******e *****:k:l e*****>'A*xx*:k****al:********
I._!. e n--- er'SC)rl . . a Notary Public of 3
of IJD r`�� C,�rp' :�G,.j -.. c'=�'-_ . -_.ACounly in the slate
do hereby certify that Ed0 i rl (000 Ci,r�. personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him or her ��,, JJ
Witness my hand and official seal, this the 17 day of r"it • 211
A4.N8-a.. 1 Lam('"-------- JJ ,,11111ERG./
Jv .�` � �ERQ '�.
Notary Public '-- Q-- ,,� \O�••.•r....•.•• '.io
NIA commission expel f�
1 U�CQ IRA r
:
. •
PUBLIC i -
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