NCC221614_FRO Submitted_20220427

yJL. Soil Erosion and Sedimentation Control
C2HA114AN1 C201UN;1"Y
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 Lund -Disturbing permits are valid for tip 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 Comrol Ordinance. This penalty is up to $5000.00 per violation
per clay and is assessed daily for every day the properly is in violation. Interfering with or hampering an inspection can result in a civil
penalty without written notice.
3) The information provided oil 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 must be signed by the property owner if an individual. If owned by a company or corporation, INS forth must be signed
by an officer. director, partner, attorney -in -Pact, or other person with authority to execute instruments for the corporation and
accompanied by a complete list of all partners, managing members and registered agent~ of the company or corporation.
OWNER OF PROPERTY:
Name and Title: TURNER, LANESE A. & STAAS, JAMES P.
Company . , r.te
Signature:
ADDITIONAL FIN
Name and Title: Ic
Company:
Signature:
CIALLY RESPONSIBLE PARTY (if any):
/®f 1344 a G
NORTH CAROLINA AGENT (if any):
Name and Title: NA
Company: NA
Signature:
County, North Carolina
,``\\\10 C �r,C I,, this day, each acknowledgi g to me th he ~µ
G Q ♦�, or she signed the foregoing document: A
-� Q� s Da �2 1- "�UffiCiel Signature of Notary
,
C©
-try Public a1 ��I�a Not,
County in the state
of K- ) r,[P,100 rb nh _ do hereby certify that L 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 15 clay of M arr-A 20ZZ..
�G�-1sts _Lr 2 CINDY E COCHIE
Notary Public Notary Public - North Carolina
Chatham County
My commission expires__ la 011202.3 My Commissian Exp(&EpWPO, 2023
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