NCC222941_FRO Submitted_20220817

DocuSign Envelope ID: 8BDD290E-683E-4AFB-8D20-6232ED04F92F
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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:
0 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
aisruma7nce must ne mcivaea when
Fee Requirements:
Permit Fee: $250/disturbed acre
disturbed area.
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
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
webpage. 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 t 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 CHART), site elan. and fee.
Fee Requirements:
Plan Re uirements:
$100 flat fee
Site Plan showing property boundaries. The site plan required by the
Environmental Health or Central Permittin De arhnents is sufficient.
ALL CHECKS MADE PAYA13LE TO CHATHAM COUNTY
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DocuSign Envelope ID: 8BDD29DE-683E-4AFB-8D20-6232ED04F92F
C71 1Ai'f tiA 1 1L'l)t1it i v
4 P It 1! 1 k A It 1. l 1 N .!
Land -Disturbing
Permit Application
"The mauling 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 Pars Ph6A-Lots 501-528 & 567-581 DATE: 06-27-2022
ADDRESS OF PROJECT: Chatham Park - Near Vine Parkway
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.7246,-79.1587
PARCEL #(S): 96203
TOTAL DISTURBED ACRES or SQUARE FEET: 2.68 ac
PURPOSE OF ACTIVITY: To grade out lots in preparation for building structures.
FEE AMOUNT SUBMITTED: $1,500.00
**LANDOWNERAS) 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, clo Rabin Rose _ Phone: !I 9-!jZ I boa
Address: PO Box 3557 E-Mail:
Cary, NC 27519 _ Signature:
**FINANCIALLY RESPONSIBLE PARTY (annlicable only if different from nronertvowner
Name: Tri Pointe Homes, c/o Bob Davenport phone: [phone]
Address: 1330 Sunday Dr, Suite 101 E-Ma' , [e-mail]
Raleigh, NC 27607 Signs b �aut lrtrbY�
814ABNUFC048A...
NORTH CAROLINA AGENT a licable only if owner or fmancially responsible party does n t reside in
North Carolina)
Name:
Address:
ENGINEER/SURVEYOR
Company Name: The Nau Company
Address: PO Box 810
Rolesville, NC 27571
Contact Person: Agnieszka Nau, PE
AhnnP 919-624-4875
E-Mail: [e-mail]
Phone-
E-Mail:
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Kristl Dillard
Company Name: Tri Pointe Homes
Phone: [phone]
E-Mail: [e-mail]
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DocuSign Envelope [D: 8BDD290E-683E-4AFB-8D20-6232ED04F92F
f1 Soil Erosion and Sedimentation Control
C14ATI-1AM C_ :1UT _rV
H., „ 1 i< { * K,l 1 9 4 A Financial Responsibility/Ownership Form
PLEASE READ THE FOLLOWING INFORMATION:
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 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, attomey-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 or corporation.
OWNER OF i
Name and Title:
Company (if apl
Signature:
Chatham Park Investors LLC
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title: Bob Davenport / Vice President
Company: Tri Pointe Homes
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
I,. _y l l� VnO , a Notary Public of County in the state
of hereby certify that 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.
Witness my hand and official seal, this the day of .20
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IC
Notary Public t �, `y �,�Z� D�AI�
n�
My cor nission expires� UUl _ ( )
V.— COIJ's;_w
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