NCC215369_FRO Submitted_20210929

C"A I:11 11AAI IL'4 )I IN, I 1
it l t l • , ,< t l t
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
your project and then check one of the boxes below:
Rel 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 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:
Desiun 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
web a e. 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
nnnlirntinn (ifrerniirerl. qee nnte 4 nn PF.F2MiTTING FLOW C'HARTI_ Site elan. and fee.
Fee Requirements:
Plan Requirements:
$100 flat fee
Site Plan showing property boundaries. The site plan required by the
Environmental Health or Central Permittin Departments is sufficient.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

_ A-- Land -Disturbing
c�I I A� r I 1A ,, c << . Permit Application
PROJECT NAME: 72 MEL Mini -Storage (15-501 Mini -Storage) DATE: 04/27/21
ADDRESS OF PROJECT: 72 Marvin Edwards Ln, Chapel Hill, NC 27517
LATITUDEILONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.8571,-79.0843
PARCEL #(S): 3080
TOTAL DISTURBED ACRES or SQUARE FEET: 5.29 acres
PURPOSE OF ACTIVITY: Commercial Construction
FEE AMOUNT SUBMITTED: $3000
LANDOWNER(S) OF RECORD (attach page to list additional owners)
Please provide a complete list of partners, managing memberss and registered agents if the responsible entity or
land owner is a group of individuals, corporate organization or entity.
Name: James T. Edwards, Jr Phone: [phone]
Address: 77 Bell Cir E-Mail: [e-mail]
IRI
Chapel Hill, NC 27516-0632 Signature:~ `
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from. propertyowner)
Name: Stackhouse Development, LLC phone: [phone]
Address: 2310 S. Miami Blvd, Suite 238
Durham, NC 27703
E-Mail: jjohnson@ren!5gckb-ouse.com
Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name:
Address:
ENGINEER/SURVEYOR
Company Name: CE Group, Inc
Address: 301 Glenwood Ave, Suite 220
Raleigh, NC 27603
Contact Person: Jeff Foster, PE
Phone: [phone] x-105
E-Mail: [e-mail]
Phone:
E-Mail:
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Mike Karpinski
Company Name: Stackhouse Development, LLC
D4,-- 337-339-8302
E-Mail: [e-mail]
Page 2 of 3

Soil Erosion and Sedimentation Control
CHiAM HAM C 1 1l A Y Financial Responsibility/Ownership Form
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: James T. Edwards. Jr. Owner
Company (if ap�Cxw
cable):
Signature: -%d
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title: Jon Johnson, Secretary
Company: 5tackhouse Development, LLC
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
I, e��� ek n� Orr+t�r` , a Notary Public of 06,L- 4— County in the state
of do hereby certify that =0 r1 V% 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 of�i seal, th' e D day of 4, , 20"d -
�y ENotsfy
ELISSA SOLOMON
Notary Pub Public. North CarolineWak• County
My commission expires Cpmmise(FEFAklr�oires
March 30, 2025
Page 3 of 3