NCC222410_FRO Submitted_20220711

iA
C'1IAI I IAAA C't>!IN I Y
1,41111
Land -Disturbing
Permit Application
Please complete both pages of this form and return to
Physical Address Mailing Address
80 East St. PO Box 548
Pittsboro, NC 27312 Pittsboro, NC 27312
Phone: [phone]
For Office Use:
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 in acres for all parcel/lots. All clearing and
aisiurnance must oe mcivaea when carcuratin .custurnea 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:
Desiza 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 drainagepattern(s) on sheet 1 of the Residential General Plan.
❑ Residential Lot Permit. The following items are required to obtain this permit: completed
application (if required, see note 4 on PERMITTING FLOW C[-IART , site plan, and fee.
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

�L.
C 71 1 IX 1' 1 1 A N'l C..'( ) It.1-4' 1 V
f l 41 1 1 1 A 11 I) 1 F' a �1
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: Chatham Park Section 7.1 Amenity DATE: 10/18/2021
ADDRESS OF PROJECT: East of Freedom Parkway; South and West of Russet Run, along Grant Dr. extension
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.748262;-79.158566
PARCEL #(S): a portion of 7101 (9752-27-6874)
TOTAL DISTIIRBED ACRES or SQUARE FEET: 2.69
PURPOSE OF ACTIVITY: Community Amenity Center including Pool, Pool house and associated features
FEE AMOUNT SUBMITTED: $250 x 3 ac = $750.00
**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: Chatham Park Investors LLC, by Robin R. Rose, Registered Agent phone: [phone] Ext. 5
Address: 105 Weston Estates Way, Cary, NC 27513 E-Mail: [e-mail]
Signature:
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner
Name: David Weekley Homes, Inc./Ryan Jackson, Land Dev.Mgr. Phone: [phone]
Address: 1901 N. Harrison Ave., Suite 200 E-Mail: [e-mail]
Digitally signed by Ryan Jackson
Cary, NC 27513 Signature: Ryan Jackson Date: 2021.11.3016:06:27-01.00.
NORTH CAROL_INA_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: withersRavenel, Inc. Person to contact should erosion & sediment
Address: 115 MacKenan Drive control issues arise during land -disturbing activity:
Cary, NC 27511 Contact Person: Ryan Jackson, Land Development Manager
Contact Person: Lesley England Company Name: David Weekley Homes, Inc.
Phone: [phone] Phone: [phone]
E-Mail: [e-mail] E-Mail: [e-mail]
Page 2 of 3

Soil Erosion and Sedimentation Control
Financial Responsibility/Ownership Form
PLEASE READ THE FOLLOWING INFORMATION:
l) This section must be signed in the presence of 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 arly 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 complete list of all partners, managing members and registered agents of the company orcorporation.
OWNER OF PROPERTY:
Name and Title: Timothy R. Smith, Member -Manager, by Robin R. Rose, Registered Agent
Company (ifa
Signature: _
ble): Chatham Park Investors LLC
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title: Ryan Jackson, Land Development Manager
Company: David Weekley Homes, Inc.
Signature: Ryan Jackson
NORTH CAROLINA AGENT (if any):
Name and Title:
Company: .
Signature: _
Digitally signed by Ryan Jackson
Date: 2021.11.30 16,06,43-05'00'
1. AAViCAW , a Notary Public of Uy County in the state
of do hereby certify that. I in 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. .M
am Witnes y hand official seal, this theday of 20�.
�``�►H F799711111+++
Notar public �k��,,•��v '--- �4 'f,•���.
My commission expires��Qj
Page 3 of 3
s �
I
9
v
111300
UU Lk
''•,��I.odgyG tLS