NCC222453_FRO Submitted_20220708

C1IAT'!fAM CCI IN I Y
**. L s N d f1P ♦ �". flt (.t I t r. 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:
X
❑ 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 mcluclecl when calculating uisturbeu 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 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 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

Land -Dist
Permit Application
'The mailing and %Irret address ol'the principal place of business for the personlenlity financially responsible and
the land om ncrls) mma be pros ided. A P.O. hoN is NOT acceptable as an address.
"'It the financially responsible pctsonipartti is different from the current land owner. an agreerrment 0giied by Moth
partic^s mu%t be proi-ided allmiing the financial!! responsible part),person to conduct the land -disturbing actin itw on
the propert%.
PRO,lV(`T NAME, Gargash Resideni:e
DATE: 06/22/2022
ADDRESS OF PROJECT: 558 New dope Church Road
LATITI-DE11 ONCITIiDE OF PROPERTY AT SITE ENTP,10C'E: 35.8181,-78.9550
P,A R(-EL #(4): 82029 --------- --- - —
TOTAL DISTURBED
L R: iC•RESorSQt:1ors roc r A�RF:�on
EET: 98'438 sf (2.26 acres)
PPOSE UF.A(-T14'ITY:Hous eC ._
FEE AMOUNT SUB.131TTE_D: $_t,500
**I.ANDOWNERISI OF RECORD tattaell page to list additional owners?
Phase 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: Scott & Jill Gargash. Phone: [phone]
Addr:Ns: 2209 Angelmng Court F_Mail: [e-mail]
gmail.com
Raleigh, NC 27613 Si *nature��
**FINANCIALLY RESPONSIBLE PARTY (applicable only if t rerent from propertvowner)
N'arne: Sage Built, LLC Phone: [phone]
Address: 3434 Kildaire Farm Road, Suite 135 F-Mail: [e-mail]
Cary. NC 27518 Si_,nattarL.
NORTH C'ARO LINA AOFNT (at►nlicable only if owner or financially responsible tarty dices not residein
Norltt Carolina
Name: Phone:
Address: _ E-Mail:
Signature-,
ENOI LI R S(JRVL"Y0?R
EROSION CONTROL
C'cinf '7 � Gfdfin Lard �a'tirvc in
t s:tn tti�.tnt,., y �_.___..___..___�,_.
Perron to conOct should erosion &-wdiment
itlrlrc tit' 209 S. l uquay Ave.
control issue% arise during hint!-tlisturhiut; tactic its
Futtuay-Varna. NC 27528
, c ►`, John Dick
("out:►ut 1>ott. __.. -
C'rsrttact 1'ers n: Mike G rfitr
CompanyN;amt Sage Suit .tLLC
Phone:.[phone]
1'11+►rr: 919-5944374
l:-fail; naikegriffinCnc.rr.corn
1-- 1anl: tahndasayebutttnc.corn ____ __ _.._.._.
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K"1ti A.1 #1111 K'��11'"V t 1'
Soil Fxo%ioll and 4tdint+e°nta+titrwi t-ontrild
Mini-micial Sir•ti�>I�rnsii�ilit►ll) ner5hit► �rrrn
%0/ Rt 01 IRIJ► 1081; ('(A W1.1 /14) I-t)/1 1 f!?"1't:1Z�4Il1,S
III I A51.:_ItV.ADVIil•..I_O1,H)WIN6IN[ Ott'4AfIQN -
T 1 Thr. m'c-tt,on Oatt,t N- %tplL `i III Ibe Isn-.rnrr afa Notary
an,i-I);. nt,rnt •:rcuri. , ,, u 1 tic vxhkt lire till to (41 %cats tiara lite (late of icsu:mee If cireum t tn( ec w irrtnl, the pcnnn may he
cvtrn.i;ki G,r I') ,var. l`., the condttum, ot-the ( halham ('punts Sod I rosion and Sohineniation ( anus( (rrdm,anet t p(,n h"-a*cn
n.+:t,:. the tankt-1)artwint polImt may be toAiked toT 1inlurc to complti (kith rite I)rdujame. I1 th,: pcirwl I�. re%0kc(:. ;ill :,bier
y*crrrrs, a-a.t npnr+,val, xv wil%1aet+# until the plopoiq is once :Ipoirr in compliance wilir ( hatham ( ,n(nty r::e^nlati(,n, �3:0. upi>n
0.VI� tw';t :7•tCh .`. a': It ti I%emviIN ttlIIc) +•:tit be I9 1T!t ill ,:d 7 I F ainR( the prpIle rty 4)%k'II,:r (7IIIFor adII1Ii4-ti al (irt.an: I rC r, in':ItSl," IV-v t ir' �nL I
k +i tin that?aags Count-, S4,11 I r(r.ion :aal Sedinacar.nion If "onttol i hdin:uu'c. -fhi, penalty I. up to S if)0 t (,(. lx:r on
kiath tier c % c I) day tin property is in v tolatIou. Interfering with or hamperi I), an tnspcc I Icyn can resod In a ctyd
p t2alTk p !;((+tilt a Ilttett notice.
T he Ir.ri,rT,7atlkrn prt,v i jed on thi% form is Intc and correct to the best of my knowledge and beliefand vk a, provided by rnc; while
tt;a+irt h
i�bt„ toMI mu o lNe sigrtcsi by tit, priTerty owner if an indieadua1. 1fovvned by a ectmpany or corporaIion_ this ta•rrm naa<r be signed
by rn ++t i�rr, dtrtitor, partner. anorney-In-f"zcr. or other person with authority to exceute in,tntments tior the cornctrarion anti
ac4.,;srs (nicx by a cotnpLtc list of all partners, managing members and rt:f i.sleved agcats of the companyer tcorporation_
O«"NER OF 1
\ame arW Title:
Company I if Fable):
Signature:
ADDlTION.kLj4NANC1ALLY RESPONSIBLE PARTY (if any):
Nattar and Title:
C�otattz':uty:
Sigmature:
NORTH CAROLINA AGENT (if any):
Narnt: ,and 1-itle:
(= ornpany:
Signature:
I. T)1 anai. ni • �Ci taS .. a Notary Public of ('ounty in the state
OF hbr-4L� aro ,t t
nr%--------do hereby ceriIj that Lt2T3" /CjplgAS�, �aC� 7i�! �?At�Z Ixxr_,a>ttally
apPcared hk lure me this day and under (lath acknowledged reading the utfitrntatton ah0%c and that the
above form .%as cxccutcd by hurt or her.
witncs;, my hand and oltictal wad, this the-_� clay ul"._.._ )
JDIANA N. HEUAS
it a a NOTARY PUBLIC
Notary Public WAKE COUNTY NORTH C R ! INA
Mycontmissionexpires �7-.yp�Qi��._. (Sl:.1t.i...� .MyCom-ss;anExp,re; � S
Page 3 of 3

Soil Erosion and Sedimentation Control
C H A-1-Fi A M C LIM-Fy
N K, A a9I w• 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 o r 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. 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 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 epmplete list of all partners, managing members and registered agents of the company or corporation.
OWNER OF PROPERTY:
Name and Title:
Company (if applicable):
Signature:
ADDITIONAL FINANCIALLY
Name and Title: Aap, R
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
PARTY (if any):
n
a Notary Public of VJ4ke County in the state
of >11 e c X-0 Q. A4. do hereby certify that ,2q ersonally
appeared before rite this day and under oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her. _LffWitness my hand and official seal, this the day of , 20 7
D
Public CHR?S71NE OSBORNE
Notary NOTARY PUBLIC
My commission expires p 2 " �� ^ Z `>< (SEAL) WAKE COUNTY, N.C.
My Commimlon Expires 02-10-24
Page 3 of 3