NCC223258_FRO Submitted (5)_20220916

. Land -Disturbing
k-tA-rF4,fLAA Ca X� V Perrnil Applicalian
r' -
Pica�;e cornp Ire brash pages of this fr rm and MU" tc,: Fnr Office L s�_
Pf,msic,91 Addr=%: Mailing Address
tCiAw'31_ E10 Dox S4S
Pia -born, NC 2-n12 Pittsbror+o. NT - 27-3] 2
Phone- [phone]
Please sco PF?R.mrf-j NG F3 X) W CHART co determine which permil and plan rcquiromerEts apply U,
your pmject and cherk chock cvlc of the boxes holvw,
0 1-sand-Disturbing Permit. The fol lowirig items are ruqu i n�3 to obtain f is pcn-nit rx n jAc d
appl icition, pjans, aTjd &cs. land -Disturbing Permit appl ica ions must inchsde all parcrisliots un
oaw appkaiian with the total awmmt of diawbafloe for all pnrc&VIots. All clearing and distarbarlm
mu%,L be jnclujnd when celculatingodistirrb��ci area, _
Fec R uirCrllents:
l'.Cnrnit Fey_ $25diaturled acre
]plan Kuy ew l ee= $25M1i ace
F rounded up to the wxf whole acre.
S,wm pie, l acre or less is $500, 1.01-2 acres is $1,OW, and �-01-3 Is S I.500- ,
PLan Rcquircrurnts'
IIMe!Cipd Fran_ subrn i I. f 1? copy of an er ..;ion co¢titrul plan -cornplvt-t�d & sealyd by a professioual lalkd
sL,rvcyur, ref ssi l erlgi neorF r i stered land :�yxe architect. `I 1 is plan most meet the e[li�TIA Of the
Chatham Uounty Emsicm Cmtwl DO Re%'icw Qwcklist and incaude al applicable construction details_
TFms,-- can bo Found -on th-c Chatham Coun#y W hed Protection websiw, f,)n the F; WkM C:OMMi
wel}pa o, Thi6 Flan must satasfw all local, gWc, and fedml rn inimum tar+ r uir rle�ts.
G merxl Plan. submit (1) copy of site ply along with the ("haffiam County kesidcatia1 Geneeal Flan, Sits
plan is noc required to k- curn plet-Ed by a reign professional_ Thc l csidwtial Gencrai Plan can be found
on 6e Chatham ['ouuty Watcr,,hed Prnteetion website on the Residential OyAstruction wubpag- I adiicatc
lot drakagc paLlcm(L) oa sh=L 1 of the Residential General Plan
❑p Residential Lot Permit_ The foilowin� ilenas arcs required lu Otain this pervn it: cOmplctcd
appli-uation, site p1m, and floe_ ?ACT? 3 "F INAN i M, R ?ON 31B I1,1' VOWN ERSl1l1' FOWMV
noc uired.
Fct imn,cnL-i= 1 ]'Ian R uju i gjmenim
$I W flat fc& Situ Plan showing pmperty boundaries 'rho s.it4 pl Lw required by ilie
F.rLvironmcpW i lea9th or Con lral I'crtnitting T)eparmac11M i� L Lcierrt,
Ar,1. {:HHCYf SMADE PAYART.R To {"1 IATHAM CO UX-ry
Pnj!�e i of 3

Land -Disturbing
�r ;} M c N a- ARL a} L I M1r h
**The tmailing wad street addre:y,& of the pripcipal plaflc of business for th-c persow)untity fmancialiv and
the land owner(s) m wit be provided- A P_{ ), hGx is NOT R >tahle a"u ad r
-111f the financia4 rMPR7Tlgilile Irers oFklparty is difkN0 t fr6m t}re currbAl land ouaar, a n :9�,r-mu-eat 5igD k.'O kv hoth
p2rkics m ust be provided allawiag the np�llg T%mporksiblc pnrty per - n to conduct the ]end-listu rhin- aeli%-i[}' 010
tlau pruper-
I}Rt E[_T NAPAFE: _ CR 186 _ DATF; 2/21/22
ADDRESS OF PR4 ],I PCTt — 355 High Ridge Erne
1 AT[TUDEaDNG1TIJ I)F Cis' PROPERT ( AT SITE ENTRANCE:
PARCEL #(Sy _------- 81714
T rAL DIS1'I- BED ACM9 or SQUARE FEET: - 0.38 acres
E[TRPOSE OF Ac_'t'i=: new SFD
FEE AMOUNT SIJ W +IITTED:
35.788100 /-79.214430
pew pn)vide a oomplac li st ofpa nners, managi nQ members and rc gKiLered aged if ibu Tv-ipansibJe -e ti car
Iartd owner is a gemup n f i r- dividuals, co¢poralc organizatim or untity.
[tip; Tnplu A Homes f'frnc:441-09pi
Addreas: PO Sox 1117 F:-Tlail: laart�ip2tho�reeorg -
HoBy Sptlings, NC 27W - gym:
**F ANC' IA L.L�' YON f Ti [.F ]'r�R � - le rani if i�Fc�•nl �r�xrt rc, owacr
Name: Txhc�c;
}add rc{,,: F:-f�1aiE:
Sig mmrc:
l QFC I•H AROT,rNA } GENT {amb obk only if or f narrc ial i)f resip Ln i b t cc art}' cities riot t�5id� i�
&ftr C'.arclllfi
N wne P5K) te:
Sim:
�.T+I�TNT•.RR�S LIR��•Yf�l�
[:Grape y Name: ib!!wdentlal Land 6ervkxx, PLLC
Address: 1917 Erns Fed
care NVI 27513
Contscx Pmom Dom Rhodes
pMm: !919-37&-!931G
E,M,il: deanort-m-oom
KROS10N COIVTROJI,
13"son to crintxtti s1tou Id ermiun & std:meat
control im uues -iriw duri ng Iaad-dis[ u rbftg activit_r.
Ccyntact Persuu; David pail
C=pany Name;
Fh ne: S1 7�• 1 j�B
E-Mail: david��l�hnmea.org
PaEglt2Of3

��ra►�r.�� �u�-ram•
Soil Erosion and SWimontation Control
Fi nancW Responsibiliiyl wnersUp Form
No jr Rl.: Q djfRP"f] To BE CO3VPLL,,-f'fif) FOk R ESIDENTUL L07' PPER,�=-
PLI A 51 i REA U 'rHE FoL LQ INC i IN- OP MAT ON
) "LU!s wo iorL must be signed in the FmL,&nee 01 a Notuy
P) AI I Lan d- I A N L Lwh 10 g peemit5 are +slid fnr up tLr (2) ycst3 fmm the data 17.P ixxuwpbeL Tf c ii rawyotmw s ummin1, 1 he rmwmit msg he
eXbMdW rUr (2' ymr-� por the conditiom of the C_hulrharn Counry Soil F.mskm and "Iedi mwmation C.Gbtr4oL Qrdinwxe. I J jtm VmLtem
Fmdce_ the LandDisturbiny, Irormit 1YIti}' be ICVoked for fai I 1Lr u�i11471y ith the CCti e. I f Lhc permit is rcwc kcd. nl1 M er
permits and sppavurils ;are wi adkid and I dw properi;+ is qrK! aZiu iu oompl iancc with Chatham CuunLy regidatiom. Also, upon
WnLtA-,r) 1101 iue, I ciVl pcMIty (FEOC) CaJ1 be ir5$LIA2Ec d asgA[nst the pmperty-uweier andfnr addhicmi Rmlir dly Ft!-fK ri9iblc pany (if any)
for vioLutions 4X Om f lh2fham Co rrty Sail Era -ion and !Y11menwion C4nraL UTIJsnimoe_ • I his penalty is lip 10 550W-DD pea a Olatioa
prr day and is a i 4UAy kw a!%,m • day the proportl+ is in viril,uinn- YnLerfeli 159 with cr hmupenTK ;m ifKpecfion tmn resalt in a civi I
peullty withvUL wriuGn ieoticc—
3) 'f he ueEormatinn prai idod on LW.. Puna is iruc s r d oornect to the bit uP my k imwkc4c and belkfaad wiz prsrM irlod h} roe hi]e
under rratlt
4) This f�= muxL Ede %rood by the proms y uwnar i f 2m ind"rvidL.lal. If owned by u vonVAny -or oxpomdm tbds form must he Mpid
by an effacer, d3rcoW, partner, a114 rude-in-fhct, oT other gram wide aulhariW to cxoMe ingrnunerktq fiw the earporati� and
secompankd by a cum*w lid of all partrLcrs_ Fawm?jnp members an d rq9iat�r.;��rje
d nLs cof the 001q ny ar oaapcwWbun.
OWNER OF PROFFRTY:
C43ffkP°M if pli 7c _ Tripll.'�fl H mes
SigEMWR: i
ADDITIONAL FI AEI C'IAL LrY RESPONSIBU PA RTY (if any):
Name and Title'
Cc y:
S(Pat =
N()«WrK CAROUNA AGENT Ofairy ?=
Namr, $red Ti Llr:
compady:
S3;gnamm:
4 p.� pp /R a Notary Public *r � cCrLllSi+f in the l�
of b � d llY �n twrrhy certify Lhat -� -,cmn I I}.
appeamd hcfaru me LYLis day and ender {lath acknowleAged riding the infemiali o=: above and aoknrrw1a1&,,cd dIaL the
above thrm was exccu ed lyy hurl or her.
W-Lc css rrLv hand and offxca seal, lhig the t dam. of 20
N utuTy Public 2-1
O TA p I,
MY mmmiss'on cMgirM � � ' i (SE -AL) � L
-P L I
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