NCC215229_MODIFICATION Supporting Doc FRO Info_20210928

[a I I XF1 I .A M CC-) t.1N`IFY
N 11 It l t1 C n it I's 11 N A
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
Phone: [phone]
Please see PERMITTING FLOW CHART to determine which permit and plan requirements apply to
�lrx project and then check one of the boxes below:
yfLand -Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, and fees. Land -Disturbing Permit applications must include all parcels/Iots 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
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
Desien 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
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.1
€ t .I,, t
CIIA'I'IIA64 C (1lIN"('Y
A 11 to I I 1.7 ,\
La11(l•• AStII1'l)ing
Permit Applit~ttti(Iri
* 1"I'lle mailhll; all(] sires( atldross of (Ile lW11101)111 place of busilless for the per,son/entity Cnaltcially responsible and
(lie Iand ot'vner(s) Inns( be provided. A 11.0, box is NOT accephtble as an add)-css.
* 11rlhe financially responsible persott/pslrty Is differellf from lilt current hold mvrrer, IIII 119110e111ent signed by both
parties must be provided allowing (Ise livallcinlly responsible 1)n1•ty per:sols io corldltcl the load-dls(urbhlg ac(fvi(y Oil
list, property.
rltoJE,cT1vnM1,: 1�_ c[?.. a-r �.�Cl"S�` I)Xrr: 8lc.lz (ten-1
nnl)Itl,ss UIt PROJECT: ?'-�3 9- _0c� (I�/
LATITUUCMONGITUDE OF PROP +;RTY AT SITE, rNTItANCr: Z5,'"t94—c�—f--7(—>l-, IUD I
PARCEL /1(8): A V—P4YZ RI 2!?1 34-
TOTAL DISTURBED ACRES orSQUAItT':F11;M T,15
PURPOSE OF ACTIVITY: LAoQ alb 4 Sio Lk;
I+le,il.AMOUN'I'SUI)MI'1•'I'LU: $6QO r-.6mIL---� C,
"LANDOWNLR S Olr RECORD attach )a 1C to list additional owners
Please provide a complete list of partners, managing members and togistered agents if the responsible entity or
land owner is a group of individuals, corporate organization or entity. ,,Qy
Name: l� AIO� Pllone: y$`Z�a /d�7�
Address: H-Mail: brus A:� Q .km
Signature:._-_
*-hPINIA'Nir`IA r (v Rr-.gTP+ITf.q[n1.17 PARTY (nmilirable only if diff0l'e111' f'I-nM 11r•nl PLIVn1001IPh)
Na1ne; Q�S e! - -She r r-cllhane:
Atfdress:' 11 f (k L'-Maii:.-�� �Pt1r� _ - re�S.ka r ""- • � '1
l-+P l G � � Sigiratnrc:
NORTH CAROLINA AGENT a-mlicable only if owner or financially responsible oar! r (100.9 110t 1-csidc in
North Carolina){
Nan1c:� �� 5 fL /.1e rrr-A Phone:
Adciress: '701 i /f� Ti-Mali:�Icleetrl � rv'
� P�-SC:� '-� i`SigntlElu•c:
L'NGINI_ ER SURVEYOIt fpa,!rnW.- EROSION CONTROL
Company Nslmc;t ►.±'Y __ ,Vi -. P-.G I'el'son to contact c['nslou & sr(Tiulcolt
Address: issues 111.180 (Itu•lttl; 111n(I-tlisturbhtl;nclivlly
�12�T.J�1�,��j�SJ,�a Contact ]let:sun; .aG�,l�` y[�C�_�j,Ci2f�IS
Contact Person: _—.- - Company Name:
H-Mai1:(3 t y1 r-A_C--Q'-n_ I:-MIIi1: ". ,iCIO Yr"15(�CdYr-•m65, CC-"+
Page 2 of 3

DocuSign Envelope ID: FEDE9429-BAOC-4078-A646-744B393465FF
C�t-rnr�-r�tvi C:cir.rr�l•rt•
Soil Erosion and Sedimentation Control
N 11 It"I fI V A 11 [i 1. 1 x A Financial Responsibility/Ownership Forin
NOT IREQUIIZLD TO BE' COMPLETED FOR RESIDENTIAL LOT PERMITS,
PLEASE READ THE FOLLOWING INFORMATION.•
1) This section must be signed ill the presence of a Notary
2) All Land -Disturbing permits are valid for tip 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 pormit 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 andlor additional financially responsible party (if any)
for violations of the Chatham County Soil Erosion and Sedimentation Control Ordinance. This penalty is up to $5000.00 per violation
per day and is assessed daily for every clay tire property is in violation. Interfering with or hampering an inspection call result irr a civil
penally without written notice.
3) Tile hrformation provided on this form is true and correct to the best of my knowledge and belief and was provided by me while
under oath.
4) This form must be signed by the property owner if au individual. If owned by a company or corporation, this form must be signed
by an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for fire corporation and
accompanied by it complete list of all partners, managing members and registered agents of tine company or corporation.
OWNER OF PROPERTY:
Name and Title: 'Fe r rA 4- r-� c_, p K"
Company ()flu
Signature:?
ADDITIONAL FINANCIALLY RE, SPONSIBLE PARTY (if any):
Name and Title: tt-ey C c3 _ C�a.K
Company:r Q P r'1PS'
Signature:
NORTH CAROLINA AGENT (if any):
LJ r S t
Name arld Titte: ' f V-c-1 e,�' U i S t
Company: r e P 4-6vy-,e <z-
Signatuure: - --
a%k�k�}R��Fxk���y::,l•>;:�ksk����esti$:�;xxx>k>k��k�e:k��k�exx
a Notary Pundit of County in the state
of do hereby certify that j e_rat personally
appeared before ine this day and under oath acknowledged reading the inforrnation above and acknowledged thattlue
above form was executed by him or her.
Witness my hand and official seal, this the_. day of S _mhZ r , 20-21 .
0, 0 ryot
Not ry Public JESSICA D MUD50N
NOTARY PUBLIC
My commission expires DWM)COUNTY, NC
my comrmssw Explrms lo. -,30 -2 q
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