NCC221376_FRO Submitted_20220407

j i, .A A 1 4 } �,� i� Land -Disturbing
Permit Application
cation
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 Reauirernentc
Permit Fee: $250/disturbed acre
Plan Review Fee. $250/disturbed acre
Fees are rounded up to the next whole acre.
Exam le: I acre or less is $500, 1.01-2 acres is $1,000, and 2.01-3 is $1,500.
Plan Requirements:
+ MA n 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 re iuirements.
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 drains a patterns) on sheet 1 of the Residential General Plan.
0 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 reauired.
Fee Requirements:jfEnvironnmental
R uirements:
$100 flat fee Plashowing property boundaries. The site plan required by the
Health or Central Permittin Departments is sufficient.
ALL, CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

L 1 iIA I r f.1,`.t ( 'c tl l.-, l i
Land -Disturbing
Permit Application
"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: 88 Maple Springs Ln DATE: 1/11122
ADDRESS OF PROJECT: 88 Maple Springs Ln, Bear Creek, NC
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.644060 /-79.475410
PARCEL #(S): 72505
TOTAL DISTURBED ACRES or SQUARE FEET: 18,342 S�
PURPOSE OF ACTIVITY: new SFD
FEE AMOUNT SUBMITTED:
**LANDOWNERS OF RECORD fattach page to list additionalowners
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: Alvin Marguerat
Phone- 919-522-0879
Address: 412 N Waters Edge Drive
Durham, NC 27703
"FINAL\
Name: Na
Address: n/a
n/a
E-Mail: a
Phone: n/a
E-Mail: n/a
Signature: _
NORTH CAR )LINA AGENT a licable onl if owner or financial) res nsible party does not reside in
North Carolina
Name: n/a Phone: n/a
Address: n/a
n/a
ENGINEER/SURVEYOR
Company Name, Residential Land Services
Address: 1917 Evans Rd
Cary, NC 27513
Contact Person: Jeff Reynolds
Phone: [phone]
E-Mail: [e-mail]
E-Mail: Na
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Jay Guido
Company Name: Schumacher Homes of NC, Inc.
Phone: [phone]
E-Mail: [e-mail]
Page 2of3

t t l! i. i t Land -Disturbing
Permit Application
**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
the property. person to conduct the land -disturbing activity on
PROJECT NAME: 88 Maple Springs Ln DATE: 1/11/22
ADDRESS OF PROJECT: 88 Maple Springs Ln, Bear Creek, NC
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.644060 /-79.475410
PARCEL #(S): 72505
TOTAL DISTURBED ACRES or SQUARE FEET: �7 O�O
PURPOSE OF ACTIVITY: new SFD '
FEE AMOUNT SUBMITTED:
**LANDOWNERS OF RECORD attach pagtLoqjist 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: Alice Marguerat phone: [phone]
Address: 412 N Waters Edge Drive
Durham, NC 27703
P
Name: n/a
Address: n/a
n/a
E-Mail:
Signatu
;able only ifdifferent from ert owner
Phone: We
E-Mail: n/a
Signature:
NORTH CAROLINA AGENT a licable only if owner or finaneiall res onsible art does not reside in
North Carolina
Name: n/a Phone: nla
Address: nla
n/a
ENGINEER/SURVEYOR
Company Name: Residential Land Services
Address: 1917 Evans Rd
Cary, NC 27513
Contact Person: Jeff Reynolds
Phone: [phone]
E-Mail: jeff ils-nc.com
E-Mail: Na
Signature: _
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Jay Guido
Company Name: Schumacher Homes of NC, Inc.
Phone: [phone]
E-Mail: [e-mail]
Page 2 of 3

c',tArE-stAI" [%,unrtr Soil Erosion and Sedimentation Control
i�
!Financial Responsibili",/Ownership Form
NOT REQUIRED TO BF COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I ) 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 pernut 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 fc>rm 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 rot the corporation and
accompanied by a complete list of all partners, managing members and registered agents ofthe company or corporation.
OWNER OF PROPERTY:
Name and Title: Alin Marguerat
Company (if ap -cable): n/a — --- —
Signature:
ADDITIONAL FINANC LLY RESPONSIBLE PARTY (if any):
Name and Title: n/a
Company: n/a
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title: n/a
Company: rtla -- --
Signature: -
`*��^^k*��k*�k*�k**�**rx��k�#**�krk**+k��k*�k�k*rk�k*�k�k��k�rk�ka<�k�k�k�k��*�x*
I' �k�d� a Notary Public of
County in the state
of do hereby certify thalt�Yin l�t y—E—C
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 rc
Notary r is pcYa-,
My Cotttmission expires c
seal, this tile._day of 2021
X
Page 3 of 3
(SEAL)
At
�v 2
t4oTARY
vusuc �
` "**"� A��

Soil Erosion and Sedimentation Control
C*#IA"I 11AM t'(1t1N1'l,
"""'' ` ^ Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COAR'LETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I ) This section must be signed to the presence of a Notary
2) All Land -Disturbing permits arc 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 N instigated against the property owner and/or additional financially responsible party (if any)
for violations of the Chatham County Soil Erosion and Scdimentation 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 mitten 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 ifan individual. If owned by a company or corporation, this lurrn must be signed
by an officer, director, partner, attomey-in-fact, or other person with autbority 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: Mice Marguerat
Company (ifa plicable): nla -
Signature: Gsr -
ADDITIONAL FINANCIAL11 RESPONSIBLE PARTY (ifanv):
Name and Title: n/a
Company: n/a -- --
Signature: —
NORTH CAROLINA AGENT (if any):
Name and Title: n!a
Company: n/a —� - - — -
Signature:
1, _ , a Notary Public of ILE County in the state
of i do hereby certify that r rsonally
appeared before me this day and under oath acknowledged reading the infornta ' n above and acknowledged that the
above form was executed by him or her.
Witness my hand and o', this the ��? day of , t.t`l
Notary P is At �,y sMy commissionex` resn4cz-AA,
5
Page 3 of 3
2(I2z. aQ
�2
"f)I PAY U
(SEAL) •°
c15gti�G +�
a
COU