NCC215204_FRO Submitted_20210916

Land -Disturbing
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
Phonc: [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:
El Land -Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, and fees. Land -Disturbing Permit applications must include all parcels/lots on
one application with the total amount of disturbance in acres for all parcel/lots. All clearing and
disturbance must be included when calculatiniz 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: I acre or less is $500, 1.01-2 acres is $1,000, and 2.01-3 is $1,500
Plan Requirements:
Desi��n'. submit (1) copy of an erosion control plan completed & scaled 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 plan must satisf 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(%) on sheet I of the Residential General Plan.
❑ Residential Lot Permit. The following items are required to obtain this permit: completed
application if re wired, see note 4 on PERMITTING FLOW CHART), site plan, and fee,
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
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Land -Disturbing
Permit Application
PROJECT NAME: Lot 87 The Summit
ADDRESS OF PROJECT: 60 Cotori Ct, Pittsboro, NC 27312
DATE:: 08-02-2021
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.77 79.09
PARCEL #(S): 88396
TOTAL DISTURBED ACRES nr SQUARE FEET: 5682 sq. ft.
PURPOSE OF ACTIVITY: Residential Construction
FEE AMOUNT SUBMITTED: $500
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: Sage Built LLC Phone: [phone]
Address: 34334 Kildaire Farm Rd. S1e.135 E-Mail: harry sagebuiltne.com
Cary, NC 27518 Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
Name: Sage Built LLC Phone: [phone]
Address: 3434 Kiida4e Farm Rd. Ste. 135 E-Mail: [e-mail]
Cary. NC 27518 Signature:
NORTH CAROLINA AGENT (applicable only if owner or finaucially responsible Party does not residein
North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEEPUSURVEYOR
Company Name, Griffin Land Surveying
Address: 209 S Fuquay Av,
Fuquay Varina, NC 27526
Contact Person: Mike Griffin
Phone: [phone]
E-Mail: [e-mail]
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land-disturbingactivity;
Contact Person: John Dick
Company Name: Sage Built LLC
Phone: [phone]
E-Mail: [e-mail]
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Soil Erosion and Sedimentation Control
4214A1'11iAM C:K?IJNI Y Financial Responsibility/Ownership Form
T A
PLEASE READ THE FOLLOWING INFORMATION:
1) This section must be sib ed in the presence of a Notary
2) All Land -Disturbing permits tyre valid for up to (2) years from the date of issuance. 11'circumstances warrant, the permit may be
extended for (2) years per the conditions of the Chatham County Sail Erosion and Sedimentation Control Ordinance. Upon written
notice, the Land -disturbing permit may he revoked ror failure to comply with the Ordinance. 11' 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 parry (if any)
for violations of the Chatham County Sail 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.
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 ibrm 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 attd registered agents of the company or corporation.
OWNER OF PROPERTY:
Name and Title: Harry Krohn VP Sags Built
Company (if applicable): Sage Built LLC
Signature:
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Flame and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
a Notary Public of t'l.k County in the state
of ' A do hereby certify that t 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 day ofO�����`�
A�G ! I G- �•g�'`co
lllTA:Gn�q 7p s
Notary Public •� a r
My commission expires�1�— (SEAL)
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