NCC241812_FRO Submitted_20240613

�,�` Soil Erosion and Sedimentation Contrfr
____SHAM C'<7UNfY
Financial ResponsiltilitylUwnershi l
p Form
NOT REQUIRED TO IIE COMPLETED FOR RLS/DEt',V�1AL LOf PF.'R,1 f17$
PLEA IIEAP THE FOLI OWING IN�k � •
II This sccrinn must he•,cn..i i'the presence ofa Ni•lary-
2)Thi-s limn must lx signed hy the
.If
director.partner.adnane -in-feel or otherpty person Oh audio'ltq to i.%ccute ntsttrumentspfor the otpt 'this form most X si wcr,
partners,Mknagiag members and registered��of the company or corporation. a a`GOnvinica M a 04^.lira„t s�
31 this form must also he signed by the financially n-,ponsible party ands agent(if applicaahkl.Same or12 t�a",,
4)If the landowner and financially responsible pally ate different,the completion and signing f this e
acknowkdginr the tam os Der consents to and tutnnraces the financially responsible party to undertake the Posed lar.}d ion c t it.landouner's teat t(s)of land identified on this application.
5)An Landd--Di is urbin ppin is are%Aid�uprue on(2))yyarsbfm the best d�eyot issuance.I(inlumasan;es i saran d by D."htk urge,oath.
(2)years per the conditions of the Chatham Coolly Soil Erosion and Scdimentatioo Control Ordinance,l.'p„nw�tt'llen i ma) be extndN fir
permit ma, he revokol for fnilen to comnl. With the t'Mdinanee If elm perr,i•. is n•rn1 el natgtlTrra end t k,Iht Iaad-Iyisru,b
' I ir.. 'I i.l ,F,rn i.;n..n, rtan',;L,o, ,,,,_k ,q..�r.,.ric.cn notice,srr•t,hr Ii. m.,1A%u,`•ithbII rr;,,
41
1•I. 5rr, -.,r,I I..,cwl.nar of the Chrehum ,romm
t. . tt tt. , , ' I .. r u,r;i -ai t .r I,11 [tie dad and is assessed dady:ur he de.ln,'"•''•nJ
,r..r... .'t9•. _. . ' •. ..u,r_ n.,ri,i . .\ a• t .iiI itlau.l„ritt.n nntroe. ry nuaenr a¢,wt.i....,•
OWNER OF PR PARTY: /' 1� -
Name and Titre' 4!8IY-�T_ ' durJ •
Company(ifap cable)- '
Signature. —
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title:
Company:
Signature -
NORTH CAROLINA AGENT(if any):
Name and Title:
Company: -
Signature: - . -
*******x..* ****************************************fit***********ts**
tt1GG
G C-4. ;eV. COLAw^nh+,a Notary Public of 176U Ay :se.-- � _County in tau state
of I�1zyy11-s Caro I.s.t.. do hereby certify that At�b�u_ t (�. 13u�� _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.
Witness my hand and official seal,
this the the I471. day of 1\-p r;1 •20Z`lt ,at t%% t are^,.,''
Notary Public --I_
My commission expires 1-1 -(—Z.bZ-`-f (SEAL)"rn• PUBLIC'
"'MANS C
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