NCC215939_FRO Submitted_20211027

1 DocuSlgn Envelopes ID 7C13DDAO-EBDE4912-A3F9-77E73113960E
Land -Disturbing
C I Ens I ANI CCJ I If`rr3r 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:
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 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: I 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 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.
[a Residential Lot Permit. The following items are required to obtain this permit: completed
application (if required. see note 4 on PERMITTING FLOW CHART), site plan, and fee.
Fee Re uircments: Plan Requirements:
$100 fiat fee Site Plan showing property boundaries. The site plan required by the
Environmental health or Central Permitting Departments is sufficient.
ALL ClILCKS MAUL PAYABLE TO CHATHAM COUNTY
Page 1 of 3

EnVeWeID 7r7CI3DCAii-E60E-4912-A3F9-77ET3li3%OE
Land -Disturbing
%to a o e. a► Vats is a. Permit Application
**The mailing and street address of the principal piacc of business for the pemon'entit► linuncialh responsible and
the land ownerts) must be provided. A P.O. box is NOT acceptable as an address.
**If the fin_enciatl\ responsible pemonlparty is different from the current land winer, an agreement signed bN holh
parties must be pro►ided allwaing the financinih responsible parr person to conduct the land -disturbing actiN il} on
the property.
PROJECT NAME. Midland Preserve Lot 5
ADDRESS OF PROJECT: 474 Midland Preserve
DATE: a1412021
New Hill, NO 27562
L.aTITUDFJLONGiTUDE OF PROPERTY AT SITE ENTRANCE: 'Ss15,4'21241407'G -7 9792W15.721e77
PARCEL, #tS): 0092009
TOTAL DISTURBED ACRES or SQUARE FEET: 1-5 BcdEs
PURPOSE OF ACTIVITY. New Construction Single Family Residence
FEE AMOUNT SUBMITTED: $750
"LANDOWNERS OF RECORD attach page to list additionalo\%ners
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 entit\.
Name: Vladimir & Jane Korobov Phone:
mdw
Address: 15 TREETOP LN E-Mail: lv [[ ��°� ��s`° SAN MATEO, CA 94t02 Signature is �r
� _
"FINANCIALLY RESPONSIBLE PARTY (applicable onIN if different front VropertN owner
Name: Hearthstone Luxury Homes Phone: [phone]
Do -5 , d 6y:
Address: 1004 Manor Glen Way E-Mail: , J� :on,
Raleigh, NC 27615 Signature: oo7scx3e+�
NORTH C AROt INA AGENT (applicable onls if owner or linancinik responsiblc part\ dues not reside in
North Carolina)
Name: Phone:
Address: E-Mail:
ENGINEEWSURVEYOR
Compam Name: RLS
Address. 1917 Evans Road
Cary, NO 27513
Contact Person: Dean Rhoads
Phone [phone]
E-Mail_ dean@rls nc.com
Signature:
EROSION CONTROL
Person to contact should erosion S sediment
control issues arise during land-disturbingactisity:
Contact Person: Bruce O'Connell
Cornpan} Name: Hearthstone Luxury Homes
Phone: [phone]
E-Mail: boconnell@arhomes corn
Page 2 of 3
I

t■
�n Envelope ID 7C13DDAD-E8DE-4912-A3F4-77E73113960E
Soil Erosion and Sedimentation Control
F�IAM COLINiY
" ' " I. A w "' r N ' Financial Responsibility/Ownership Form
PLEASE READ TI [E FOLLOWING INFORMATION:
1) This section must be signed in the presence of 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 penally 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 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 orcorporation-
OWNER OF PROPERTY:
Name and Title: Vladimir & Jane Korobov
Company (if applicabl W
Signature:[13".34;iavi
akrKir g jakL
,nsazwsIc,,,ra
6i,6 bk
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title: Jeff Lc
Company: Hearthstone
Signature:
PresidenttOwner
r Homes _
NORTH CAROLINA/AGENT (if any):
Name and Title:
Company:
Signature:
k���*%o;�k�F�k%k*kkFaFk�F*kk����k�!c�hkkkk=kkkk�l=*�kk;c�:�4;c!c*;ckkk:E��%kk�>K3,ck$c�cx
yj 8 a Notary Public of ���-�1 ` County in the state
of do hereby certify that�ae _' S 6 � 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 hated and official seal, this the day of­� , 201� l
J:� n A,— TRINA M LOGSDON
NOTARY PUBLIC
Votary Public Wake County
��a3 North Garolin
emission expires My Commission EKPIres ( f
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