NCC221377_FRO Submitted_20220407

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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, deed, and fees. Land -Disturbing Permit applications must include all parcels/
lots on one application with the total amount of disturbance for all parcelAots. All clearing and
disturbance must be included when calculatinfa 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
web a e. This plan must satisfy all Iocal, 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 pa lan(s) on sheet I of the Residential General PIan.
111 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

CV( .rf-9A - CIO U' T-Y
Land -Disturbing
Permit Application
**The walling and street address of the principal place of business for the persoulentity financially responsible and
the land awner(s) must be provided. A P.O. box is NOT acceptable as an address.
**If the financially responsible persoulparty is different from the current land owner, an agreement signed by moth
parties must be provided allowing the financially responsible party person to conduct the land -disturbing activity an
the properly.
The Preserve
"M�WA - LOT 261 E
PROJECT NAME:
ADDRESS OF PROJECT:
DATE:
80 Forked Pine, Chapel Hilt, NC 27517
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE:
PARCEL #.(S):
0077372
TOTAL DISTURBED ACRES or SQUARE FEET: '13
PURPOSE OF ACI IVyry. Residential New Construction
FEE AMOUNT SUBNUrM: $500.00
March 3, 2022
N48 2T 56" W
**LANDQMMR(S} OF RECORD (attaches a to list additional owner
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: Hatem & Julie Tolba Phone: [phone]
Address: 5512 Teversham Way E-Mail: oltJ all.cam
Cary, NO 27519 gibe• `
FiNANCTALLY RESPONSIBLE PARTY livable only if different from ro owner
Name. Gephart Building Company, LLC Phone: [phone]
Amass: 4016 Barrett Drive, Suite 201 E Mail:
Raleigh. NC 27609 ._ X Signature:
NORTH CAROLINA AGENT a livable on1 if owczer or fir;az:ciall onsible does not residein
North Carol
Name:
Address:
rua
Phone:
FImail:
Signature:
ENGDW RJSURVEYOR EROSION CONTROL
CA)mpany Name: Residential Land Services Person to contact should erosion & sediment
Address: 1917 Evans Road control iEssaes arise during irk land-disturbingacthitV
Cary, NC 27513 Contact Person:
Contact Person: Dean M. Rhoads
CompanyName: Gephart Building Company
Phone: 919 378=9316 Phone.
UMaU: deangris-no.corn E--Mail:
Page 2 of'3
919-369-4466
[e-mail]

Soil Erosion and Sedimentation Control
K " Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS
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. AIso, 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 farm is true and correct to the best of my knowledge and belief and was provided by me while
under oath
4) This form mast be signed by the property owner if an individual. If owned by a company or corporation, this farm 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: Hatern & Julie Tolba
Company (if api
Signature: A
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title: Richard Gephart, Manager
Company:
x Signature:
NORTH CAROLINA AGENT Many):
Name and Title: nla
Company:
Signature:
I D,!%rd z:X r_ a Notary Publie of I- County in the state
of N e- - do hereby certify that personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her.
Witness my hand and official seal, this the ^day of 1--k A4 cif , 20aa.
i
Na Public FWAKE
AMES A. OLIVER
y NOTARY PUBLIC
My commission expires (SEAL) COIiNTY, N,C.
nnisafon Eacpiras 1I 43-2022
Page 3 of 3 4

I, U��.� --7 , a Notary Public
of W w1b, County in the
state of N /, ,,, , do hereby certify
that P C��G242 A"In �--
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 �`� I � � a �a� day of
,( y2022.
aa.i 2-I,.�+-c__ !/a.......,....n
Notary Public
My commission expires
-- � -3Q , a.1 �- t7
JOSE VELAZQUEZ PAYANO
Notary Public
Wake Co., North Carolina
My Commission Expires Sept. 30, 2024
0
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