NCC221210_FRO Submitted_20220330

CUATf KAM CC)UK-F-V
N l7 It 7 H C' A R" I. I 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
your project and then check one of the boxes below:
❑ 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 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
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.
❑ 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
Page 1 of 3

1r--1
Land -Disturbing
CI t. k I i C- Cc7- it N A Y Permit Application
�i c)It � �i c-� unc-rNA
**The mailing and street address of the principal place of business for the person/entity financially responsible and
the land owner(s) must be provided. A P.O. box is NOT acceptable as an address.
**If the financially responsible person/party is different from the current land owner, an agreement signed by both
parties must be provided allowing the financially responsible party person to conduct the land -disturbing activity on
the property.
PROJECT NAME: Westfall Lot 10
DATE: 2/4/22
ADDRESS OF PROJECT: 231 Beech Slope Ct., Chapel Hill, NC 27517
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.8283/-79.0499
PARCEL #(S): 90752
TOTAL DISTURBED ACRES or SQUARE FEET: 0.29
PURPOSE OF ACTIVITY: New SFD
FEE AMOUNT SUBMITTED: TBD
"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: Westfall Associates Phone: [phone]
Address: 9381 Bartons Creek Rd. E-Mail: [e-mail]
Raleigh, NC 27615 Jan Futrell Digitally 2.04 an Futrell
g Signature: Date: 2022.02.04 15:31:00-05'00'
"FINANCIALLY RESPONSIBLE PARTY (qpplicable only if different from property owner)
Name: ICG Homes, LLC Phone: [phone]
Address: 4020 Wake Forest Rd. Ste. 306 E-Mail: [e-mail]
DigiRaleigh, NC 27609 g Ryan Perry Date�12022.02ly .04y15y31 Perryan -00'00'
g Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Taylor Land Consultants, PLLC
Address: 1600 Olive Chapel Rd. Ste. 140
Apex, NC 27502
Contact Person: Jeremy Taylor
Phone: [phone]
E-Mail: [e-mail]
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Ryan Perry
Company Name: ICG Homes, LLC
Phone: [phone]
E-Mail: [e-mail]
Page 2 of 3

Soil Erosion anc! Sedimentation ('onl~rol
C,Iv%I IIAN't C;c ���� t l
Financial Responsibilite-/Oi� nership Form
N07'1?A;0C/I111:1> 1U) Bj; ('U:1J!'11)1•'UI?
PLEASE READ THE FOLLOWING INFORMATION:
I ) This section must be signed in the prescnce of a Notan
i All Land-Distnfiing permits are valid for up to (?) Nears from file dale of issuance. If circuna�fataces %arrant. tine 1) ranit ill, be
extended for (2) \-cars per the co»ditions of the Chatlann Counts Soil Erosion and Sedimentation Control Ordinance. Upon xintlen
notice, the Land-Dislurbing permit mas be revoked for failure to comets N\-ith the Ordituulce. If the permit is revoked. all other
perims and approvals are aitlihcld until the propern is once main in compliance faith Chatham CouutN regulations. Also. upon
x%rittetl notice. it civil penalh (Zinc) can be instigated against the propem o%\-ner and/or additiomil 17nanciall) responsible parr (if ens)
for \-iola(ions of the C'halhana COntatN Soil Erosion and Sedimentation Control Ordinance. This peiaiallN is tap to 'i0 oo.00 per \iolation
per da} and is assessed daily for everN da% the proper(\- is in violation. Interfering \\ ith or hampering an inspection can result in a civil
pcnalts \1 ithout isritien notice.
a Tile infonnafion provided on this fonn is inae and correct to the best of nn knowledge and belief and was provided b\- nee Nshile
under oath.
4 ) This fonn must be signed b� the propetl\ o\Ctler if an indi\idu al. If oisned b\ a conlpam or corporation, this form must be signed
b\- an officer. director. partner. attorney -in -fact, or other person iAilh authority to execute instnunents for the corporation and
accompanied b} a complete list of all parlr><rs, managing members and registered agents of the conapam orcorpomtion.
OWNER OF PROPERTY:
Nanlc and Title Jan Futrell, Manager
- --------- --- ---
Conlpan��licablc) Westfall Associates
Signature:
ADDITIONAL FINANC'IALI.N
Nanle and Tit!, Ryan Perry, Owner
Compam : ICG Homes, LLC
Signature:
RESPONSIBLE PARTY (if any):
NORTH CAROLINA AGENT(ifaft\-):
Name and Title:
CAnlpan\.:
Sig,nature:
4.:{X?;\X7j.'vvy..�:X:,:
1. Holly W. Brazell a Notar\ Public of Wake Count\ in the state
,)f North Carolina do hereby certih- that Jan Futrell personally
appeared before tile this day and under oath acknonledged reading the infornlation above and acknrnNl d«cd uh:attLr
abocc form \\as c%ccutcd b\ him oncer. ,,,
4th W
witncss nn hand and official seal. this the des of February :2022
_
Not.ar-, Pill) is
\1\ commission c\l)ires 08/21/26 =�: o0
<.COu o
n_ , n _t o

Soil Erosion and Sedimentation Control
Financial Responsibility/ON` nership Form
V'0%'Il/•;O1 '11U..)
PLEASE READ THE FOLLMVi\Ci I\FORMATION:
I ) This sect loll must be signed in 111C presence of it NolarN
�) All Lnrxi-Disturbing permits arc \alid for up to (2) tears from file date of issuance. If circumstances \\arrant. Ills permit maN be
extended for (2) Nears per the conditions of the Chatllinll Count\ Soil Erosion and Sedimentation Control Ordinance. Upon\critten
notice. file Land -Disturbing permit n1a\ be revoked for failure to comply with the Ordil>iulce. If the permit is re\oked. all other
permits and approvals are %aithllcld until the properiN is once agilin in conlpliallcc \\ith Clliuhaiu CountN regulations. \\ ritten notice. a ci\ it pcnalt} (fine) can be instigated against the propene owner and/or additional linanciall\ responsible 1rt\S(ifulpon
for violations of the C'halham Connh Soil Erosion mid Sedimentation Control Ordinance. This pcnalt� is up to auu.ru► per \ iolalion
per da} slid is assessed Bail\ for e\ cr\ &a the properlc is in Violation Inlerrering kith or hampering an inspection can result in a civil
pcnall� I%ithouf \\riven notice.
I) The information pro\ ided on this form is Ime and correct to file best of na\ kno\\ ledge and belief and \cas provided be tile while
tinder oath.
4) This form must be signed b\ the proper\ o\\ tier if an indh idual. If o\\ tied b% a conlpam or corporation. this form must be signed
by an officer, director, partner. attortle\-in-tact. or other person milli aut}lorit\ to execute instruments for the corporation alld
accompanied b} a complete list of all partners. nuanagim members and registered agents of the conlpam orcorporuion.
OWNER OF PROPERTY:
Name and Title: Jan Futrell, Manager
Compam (if applicable) Westfall Associates
Signature
ADDITIONAL FINAN('IAL.LY RESPONSIBLE PART) (ifany):
Name and Title Ryan Perry, Owner
C
NORTH CAROLINA AGENT (if an-v):
Name and Title.
Company
Signature:
*:**•****%!.-*Y _­\}.X X?C--1 X7':� Y
I Holly W. Brazell a Notary Public of Wake
• Count\ in the state
of North Carolina do hereb, certifi that Ryan Perry
personally
appeared before me this day and under oath acknowledged read1wi the information above and ackno\%Icdocd thatthe
abo\ e form � \Qcuted b\ him or her. ``„ipUu
Wimcss im hand and official seal. this the 4th da\. of February 2022 ° W ' 8Rq,
— — - y .. .
Notary Pu i --- i
r
'V1-% 08/21 /26 commission expires -,� ••.,�pV `�G,.
--- ---- (SEAL)
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