NCC241257_FRO Submitted_20240424

Applications may be submitted online:
https://chathamcountync.viewpointcloud.com/categories/1082
Land-Disturbing
CI IATE IAM COUNTY Permit Application
V (1 It7 IIn C Itl") l- t tV A
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
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.
0 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
CIIATIIAA4 C(71ir uv
<. It IIfA It t, t IN. A 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 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 133 DATE: 3/8/2024
ADDRESS OF PROJECT: 178 High Ridge, Pittsboro NC 27312
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.7876/-79.2203
PARCEL#(S): 81505
TOTAL DISTURBED ACRES or SQUARE FEET: - 16752_
PURPOSE OF ACTIVITY: NEW SFD
FEE AMOUNT SUBMITTED: TBD 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: Thomas and Kimberlee Beauchamp Phone: [phone]
Address: 823 Roselyn Drive E-Mail: [e-mail]
Victoria, MN 55386 Signature: Thomas Beauchamp=101,v,;,'1;,�'
**FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner)
Name: ICG Homes, LLC Phone: [phone]
Address: 4020 Wake Forest E-Mail: [e-mail]
Raleigh, NC 27609 Signature: RYan Perryoelyrrd ,737Peaa,00•
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Ryan Perry Phone: [phone]
Address: 4020 Wake Forest Ste 306 E-Mail: [e-mail]
Ryan PerryOa� ,717,7::1 <ooRaleigh, NC 27609 Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Taylor Land Consultants,PLLC Person to contact should erosion &sediment
Address: 1600 Olive Chapel Rd Ste 140 _ control issues arise during land-disturbing activity:
Raleigh, NC 27502 Contact Person: Ryan Perry
Contact Person: Jeremy Taylor Company Name: ICG Homes, LLC
Phone:[phone] Phone: [phone]
E-Mail: [e-mail] E-Mail: [e-mail]
Page 2 of 3
ANTICIPATED START DATE: 4/1/2024 ANTICPATED END DATE: 11/15/2024

Soil Erosion and Sedimentation Control
CHATF-FAM Ca LINTY
It "' C (7" Y^ Financial Responsibility/Ownership Form
NOT REQUIRED TO RE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I t This section must be signed in the presence of a Notary.
21 This form must he signed by the property uo nor if art indie idual.Ifowned by a company or corporation,this form must be signed by an officer.
director.partner.attorney-in-tact.or other person with authority to execute instruments liv the corporation and accompanied by a complete list o1'all
partners.managing members and registered agents of the company or corporation.
:)This form must also be signed by the financially responsible party and NC agent(if applicable).Same provisions of:2 above apply.
41 If the landowner and financially responsible party are different.the completion and signing of this pane shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land-disturbing actin it) on the
landowner's tract(s)ol'land identified on this application.
5) The information provided on this liirm is true and correct to the best of my knowledge and belief and was pro'.ided by me while under oath.
Cu)All Land-Disturbing permits are valid for up to(2)years from the date of issuance. If circumstances warrant,the permit may be extended tiv
(21 years per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Upon whom notice, the Land-llisuuhin
permit may be revoked for failure to comply with the Ordinance. It'tlx: permit is revoked. all other pennits and approvals are withheld until
the property is once again in compliance with Chathunt County regulations. Also,upon written notice.a civil penalty(line)can be instigated
against the property owner and/or additional financially responsible party t if any)fur violations of the Chatham County Soil Erosion and
Sedimentation Control Ordinance.This penalty is up to S5000.00 per violation per day and is assessed daily for e'.cry day the property is in y iolatian.
Interfering with or hampering an inspection can result in a ciy it penalty without written notice.
OWNER OF PROPERTY:
Name and Title: Thomas and Kimberlee Beauchamp
Company(if app('cable):
Signature: I harti��- 9Y1 .ra a41
FINANCIALLY RESPONSIBLE PARTY (applicably only if different from property owner):
Name and Title: Ryan Perry.Owner
Company: ICG Homes,LLC
Signature:
NORTH CAROLINA AGENT(Wally):
Name and Title:
Company:
Signature: •
•
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I, r�4- )a=- 0 �,cti aGi� .a Notary Public of )C( C�
rr County in the sweet:
of T do hereby certify that f ykSmct ' 't ntrcl.-0a...vt personally-
appeared before me this day and under oath acknowledged readings the information above and acknowledged that the
above form was executed by hint or her.
Witness my hand and official seal,this the rf` day of t =�G 20
Notary Public ; ADERON)EAYOBAMIODUNYODE
My Commission expires Ot .31 'S '�- SF�rPlJ3JC•MJtW OiA
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Page 3 of 3

Soil Erosion and Sedimentation Control
C 1 A FIANI COIINTY It CI I INA
Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I)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
aclmowledging 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 andfor additional financially responsible party(if any)for violations of the Chatham County Soil Erosion and
Sedimentation Control Ordinance.This penalty is up to S5000.00 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: Thomas and Kimberlee Beauchamp
Company(if applicable):
Signature:
FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner):
Name and Title: Ryan Perry,Owner
Company: ICG Homes,LLC
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title: Ryan Perry / Owner
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I, LPscI e, m, S-io r\Q. ,a Notary Public of 1I4•A KA County in the state
of Gi do hereby certify that -- Qn -Per r9 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.
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Witness my hand and official seal,this the 11 day of .20_21 M•
\-/K, •\iS.,t1TYGL) zit •%4
Notary Public ' l
My commission expires 0 �,- b '! - Dc (SEAL) ;, :'U_r
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