NCC230170_FRO Submitted_20230203

Applications may be submitted online:
https:Hciiatliamcounlync.viewpointcloud.com/categories/ 1082
Land -Disturbing
Permit Application
Please include all required signatures, 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, plan, and fee 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, deed, and fees. All clearing and disturbance must be included when calculating
disturbed area.
Fee Requirements:
See attached PERMFIFFING FLOW CHART
For fees that are rounded up to the next whole acre.
.Example: I acre or less is S500, 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.
Thesc can be found on the Chatham County Watershed Protection website, on the Erosion Control
webpa e. This plan must satisfy all local, state, and federal minimum plan requirements.
General Plan: submit (1) copy of site plan showing proposed disturbance limits 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,
Residential Land -Disturbing Permit web a e. Complete table on sheet 1 of Residential General Plan.
0 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 Re uirements:
Plan Requirements:
$100 flat fee
Site Plan showing property boundaries and proposed disturbance limits. The site
]an required by the Environmental Hcalth Department can be used as a base.
ALL CHECKS MADE PAYABLEA"O CHATHAM COUNTY
Page 1 of 3

Lane! -Disturbing
•!! \141 1tit C•a 1I1\i l
Permit Application
"The (nailing and street address of the principal place of business for the person/entity financially responsible and
the land owner(s) must be provided. A 111.0. box is NOT acceptable as an address.
"If the financially responsible party is different from the current land owner, an agreement signed by both parties
must be provided allowing the financially responsible party to conduct the lane! -disturbing activity on the property.
"Phis agreement is provided on page 3 of this application and must be completed in its entirety.
PROJECT NAME: Fidelity Bank Pittsboro
ADDRESS OF PROJECT. 24 Commerce (
DATE: 7122/2022
Pittsboro NC 27312
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.719319,-79-159118
PARCEL #(S): 79380, 82332
TOTAL DISTURBED ACRES urSQUARE FEET: 1,5 acres
PURPOSE OF ACTIVITY: Commercial Development
FEE AMOUNT SUBMITTED: $1000 RIVER BASIN: CAPE FEAR
"LANDOWNER(S) OF RECORD (attach page to list additional owners)
I'lease provide a complete list ol'partners. managing members and registered agents if the responsible entity or
land owner is a group of individuals. corporate organization or entity.
Name: Fidelity Bank by Steve McClure phone: [phone]
Address: 100 South Main St, Fuquay Varina, NO 27526 C_Mail: [e-mail] y}� `' _. p
Signature: ori�1ih &.1k �j �d. /mac 5V f
"FINANCIALLY RESPONSIBLE PARTY (applicable only if different from propertyowner)
Name: Phone:
Address: G-Mail:
Signature:
NORTI I C'AROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Phone:
Address: L:-Mail:
ENGINEER/SURVEYOR
Company Name: Capital Civil Engineering
Address: 1011 Pemberton Hill Road
Apex NC 27502
Contact Person: Michael McQuillan
I'honc: 919-249-8587
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land-disturbingaclivity:
Contact Person: Fidelity Bank by Steve McClure
Company Name: Fidelity Bank
Phone: [phone]
I -Mail: mmcquillen@capitalcivil_com E-Mail; [e-mail]
Page 2 of 3
AN I'ICIPATLD START DATE: ANTICPATED END DATE:

Soil Erosion and Sedimentation Control
Financial Responsibility/Ownership Form
A10T REQUIRED TO BE COMPLETED FOR RESIDENTML LOT PERMITS,
PLEASE READ THE FOLLOWING INFORMATION:
1) This section must be signed in the presence ora Notary.
2) This form inust be signed by the property owner if an individual. if owned by a company or corporation, lids ronn must be signed by an officer.
director. partner, attorney-in-finct. or other permin with authority to execute instruments for the cnrparauon and accompanied by a complete list of'all
partners. managing Incnthers and registered agents of the company or corporation.
:) This farm attest also be signed by the financially responsible party and NC agent (il•applicablc). Same provisions of It 2 above apply,
•I) 1I'the landowner and linancialli responsible patty arc diflercm. the unnpletion and signing of this page shall serve as dtwutncntattioa
acknowledging the landowner ctmscnts to and authorizes the rinancially responsible party to undcltake the protxtsed land -disturbing activity on the
landutcncr's traotst of land identified on this application.
51 The information provided on this lbrin is true and correct to the best ol'my knowledge and beliefatnd was provided by me while under oath.
fit Aii band -Disturbing permits urc valid for up to (2) years f'mm the date of issuance.. I r circumstances warrunt, the permit may be extended for
(2) )cars per the conditions mf the Chatham County Soil Erosion and Sedimentation Control Ordinance. Opon written notice. the Land -Disturbing
pennil may he revoked for failure to comply with the Ordinance. 11' the pennit is revoked. all other permits and approvals arc %vithheld until
dw property is once again in compliance with Chatham County regulations. Also, upon writtcn notice, a civil penally (fine) can be instigated
:against the prupcily m%YnCr and/or additional financially ressponsiblc party (irany) for violations of the Chatham County Soil Lrosion and
Sedimentation Control Ordinance. This penalty is up to S5000.00 per violation per day and is assessed daily for every day the property is in violotion.
Intcriering with or hampering in inspection can result in a civil penalty without written notice,
OWNER OF PROPERTY:
Name and Mille: Fidelity Bank by Steve McClure, SVP
Company (il'applicable): Fidelity Bank
Signature: i -hAY V'
%
FINANCIALLY RESPONSIBLE PARTY (applicable only if different front property owner):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
C'ampany: -
Signature: -- - -
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Page 3 of 3
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