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NCC233051_FRO Submitted_20231011
Applications may be submitted online: https://chathamcountync.viewpointcloud.com/categories/1082 Land-Disturbing C_i t ATi i A M COUN Permit Application A!, l Attest C, t , IVT 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: (919)545-8344 Please see PERMITTING FLOW CHART to determine which permit, plan, and fee 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, 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(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 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-Disturbing Permit webpage. Complete table on sheet 1 of 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 and proposed disturbance limits. The site plan required by the Environmental Health Department can be used as a base. ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY Page 1 of 3 Land-Disturbing CI 1 AT I t o M CC-MINTY ro. A Permit Application tiula i i e� .tau IIn **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 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. This agreement is provided on page 3 of this application and must be completed in its entirety. PROJECT NAME: Chapel Ridge Lot 741 DATE: 8/31/2023 ADDRESS OF PROJECT: 28 Willow Creek,Pitsboro NC LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: -1 C1.22 (O/ 3 ,"1 q1 SS y O PARCEL#(S): 84765 TOTAL DISTURBED ACRES or SQUARE FEET: 26,248 sq ft or .60 acres_ _ _ PURPOSE OF ACTIVITY: Construction SFR FEE AMOUNT SUBMITTED: $500 RIVER BASIN: CAPE FEAR **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: John J&Kathleen DiSanto Phone: a O--3¢ g-4411'3 Address: E-Mail: Signature:4 ) **FINANCIALLY RESPONSIBLE PARTY(applicable only if differen from propertyowner) Name: Prewitt Custom Homes, Inc. Phone: 919.669.1969 Address: 2500 Regency Parkway Cary,NC 27518 E-Mail: jim@prewittcustom es.com Signature: 9' NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not reside in North Carolina) Name: Phone: Address: E-Mail: Signature: ENGINEER/SURVEYOR EROSION CONTROL Company Name: E CLS CT,Ohxt I Person to contact should erosion &sediment Address: 1©l j . M0111n \. Si- • control issues arise during land-disturbing activity: Co CAS No, 2-1 S 1 Contact Person: Jared Hiegel Contact Person: tAYYXi C U3 C t} Company Name: 1Pr'P lam ' 0 ustrn 1-1 orne s Phone: et O. sal. ' Z5l Phone: 919.330.3220 E-Mail: (-Y\31 e uJ c e(".\S�t(' al t1(1C•COM E-Mail: Jared@prewittcustomhomes.com `J Page 2 of 3 ANTICIPATED START DATE: 9/31/2023 ANTICPATED END DATE: 9/31/2024 Soil Erosion and Sedimentation Control C'11A1'i-IA1%% CC-MINTY "" " ' " ` It" ' ' ` A 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)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. 3)This form must also be signed by the financially responsible party and NC agent(if applicable).Same provisions of#2 above apply. 4)If the landowner and financially responsible party are different,the completion and signing of this page shall serve as documentation acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land-disturbing activity on the landowner's tract(s)of land identified on this application. 5)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. 6)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. OWNER OF PROPERTY: Name and Title: John&Kathleen DiSanto Company(if applicab . Signature: FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner): Name and Title: Jim Prewitt/President Company: ewitt Cu Homes,Inc. Signature: o'it-u,celk NORTH CAROLINA AGENT(if any): Name and Title: Company: Signature: *****************************:k**************************=k********* I, &my).o. E. IV\U c\. ,a Notary Public of 0 CS(\Y\S i() County in the state of \\J 1JY VN O.GVI>\►Y�A do hereby certify that SY\Y\T t?1 1tv�� / 1 rn 1 pe onally 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 l day of NACalASt ,20 Z3. otary Public EMMA E MUt,i?E My commission expires 16 mp-e--Q-10 ' Z� NJ �1�I?UBLIC �df��t counry " ► ,x North Carotin My Commission Expires ' Page 3 of 3