NCC222824_FRO Submitted_20220809

Soil Erosion and Sedimentation Control
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Financial Responsibility/Ownership Form
NOTREQUIRED TO HE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE F0LL0W1NGjNF0R1�QN�4Aj1 :
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 I.And-Distwbinr, 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 (flne) can be instigated against the property owner and/or additional financially responsible party (if any)
for violations of the Chebarn County Soil Erosion and Sedimentation Control Ordinance. This penalty is up to S5000M 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
penally %ithouturim-n notice.
3) nie 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 fonn rntist I?.- signed by the property owner if an individual. If owned by a company or corporation, this form, must be signed
by = offi=, dkctor, partmr, attomey-in-fact, or other person with authority to execute instruments for the corporation and
accomparied by a coniplete list of a partners, managin,v members and registered agents of the company or corporation.
OWNER OF',
Name and n1c:
Cai-ipan,v f ap,
ADDITIONAL M-ANCIALLY RESPONSIBLE PARTY (if any);
N311-se . ,
corrparl'.y:
sigultze,
NORTH CAROLLNIA ACC NT (if any) -
Nang; and Tille:
Company: - — ------
a Notary Public of WrtX4-- Count in the Slate
ref , do hereby certify tbatj­ W A5 JA#
--personally
W,aredbef6rcthe this da and under oath ackii owledged reading the in forination above and acknowledged that the
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above form was cxccut.,d by lstni orher.
Witrcss nw, has-nd and official 1, this the, day of 2Q
Notary PL b I i C
My cown-,,�sicr, expires,, ­­ 14 -- F -,20.zq
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t4OTAIRY
PUBLIC
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