NCC240149_FRO Submitted_20240117

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Land-Disturbing
4.-11 1 1 1 # \ NI i `= t o t l
• 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, deed, 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 must be included when calculating disturbed area.
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:
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 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 drainage pattern(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: Plan Requirements:
$100 flat fee 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

ILAnd-Msturbing
C.4 ! ! 1 t ti Pennfitc Appllccaaflon
*''The mailing and street address of the principal place of business for the person/entity financially responsible and
the land owner(s) roast 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 provide it a➢lowfl i g the financially responsible party person to conduct the land-disturbing activity on
the property.
PROJECT NAME: Lot 548 Governors Club DATE: 10/16/2023
ADDRESS OF I"ROJ1l;CT: 71007 Everard Chapel Hill, NC 27517
LATLTUDE/LONGLTUDE OF PP'OPERTY AT SITE ENTRANCE: 35.8471/-79.0360
PARCEL#(S): 67419
TOTAL DISTURBED ACRES or SQUARE FEET: .22 acres
PURPOSE OF ACTIVITY: New residentail construction
FEE AMOUNT SUBMITTED:
**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: Domenic&Daphne Russo Phone: [phone]
Address: 1275 Covington Rd E-mail: dndrusso@sbcglobal. t
Los Altos,CA 94024-5009 Signature: — ; ( �`
**FINANCIALLY RES ON IBLE PARTY(applicable only if differ from propertyowner)
Name: 171/t G ' rl c Phone: 6
2-7
Address: 50,4fro "L f't rS r_C�- C�1 E-Mail: S
C-vl� r I C�J l, �S1' Signature:
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 EROSION CONTROL
Company Name: Civil Consultants Perso,it to contact slurnid erosion .0 sediment
Address: 3708 Lyckan Parkway Ste 201 control issues arise during land-disturbing activity:
Durham, NC 27707 Contact Person: Les Clark
Contact Person: Company Name: BOLD Construction Inc
Phone:[phone] Phone: [phone]
E-mail: [e-mail] E-mail: [e-mail]
Page 2 of 3

, r - $ - � Soil Erosio �= and Sedimentation Control
SIN-I_y
,> '° , „ . , '} a 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)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: Domenic&Daphnee Russo-Owners
Company(if ap i licable): •
Signature: *di 1-.. -051)
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY(if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGEN. (if any):
Name and Title: - tk.W el vt
Company:Signature:
******************************************************************
I, , a Notary Public of 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.
Witness my hand and official seal,this the day of 20
5et
Notary Public
My commission expires "(/• i E / , (SEAL)
Page 3 of 3

ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of Calif rnia
County of CL. Clara
On QC� p 0 3 before me, �"1irnk rk4 (nava it)64
(insert name and title of the officer) f-
personally appeared bO,,i p#,;C V. aSsp
who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand an ff' laf a S� o.r, KIMBERLYlitAEMURPHY
s, NCommotary Pubiicission California23&2743
Santa Clara County
s ^e
a ���q.��•
my Comm.Expires Nov 11,2025
Sign t .r —''' (Seal)