NCC230645_FRO Submitted_20230310

CHA-II'H1�M C�iiN`i`Y
N C1 R "T !i 4-- A H O L. D N A
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
DEPARTMENT OF SOIL EROSION & SEDIMENTATION CONTROL
A Land -Disturbing Permit must be obtained before initiating any land -disturbing activity which
will exceed (1) acre (43,560 square feet). A Land -Disturbing Permit Application, this Financial
Form, an Erosion and Sediment Control Plan, plan review fee, and permit fee should be submitted
30 days Prior to the planned commencement of the land -disturbing activity.
The above information should be submitted to: Jim Willis
Soil Erosion & Sedimentation Control Dept_
P.O. Box 130, 80 East Street
Pittsboro, NC 27312-0130
Please type or print the following information:
Date: 2.24.2023
Name of Project: Chapel Ridge -Lot 224
Location of Project: 246 fynlfars View,Pjf#shorn. NC 27312..
Acreage to be disturbed: 0.35
Purpose of activity: Build a single family home
Landowner(s) of record:
Name: Chamberlain Homes LLC
Name:
Address: 120-A N Salem St
Address:
Apex, NC, 27502
Telephone: Home
Telephone: Home
Office 919.796.0953
Office
Fax
Fax
E-Mail
E-Mail
Indicate Book and Page where deed or instrument is
2265
Book
Page
PIN# 973400438777
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. 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. If the person financially
responsible is not a resident of North Carolina a North Carolina agent must be designated. if someone
other than the owner is financially responsible, their signature is required below also.
Name of individual
Title find Name of Company
;Oie 's S, ure
NC agent's signature (If applicable)
Additional Financially Responsible
Party (If applicable)

PLEASE READ THE FOLLOWING INFORMATION:
All Land -Disturbing permits are valid for up to (2) years from the date of issuance. If
circumstances warrant it, the permit may be extended for (1) year 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 he 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 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.
11A KIP
STATE OF NER'S SIGNATURE
COUNTY OF
1,W"I&Xd , a Notary Public of said County and State, do
hereby certify that personally appeared
before me this day and under oath acknowledged reading the information above and
acknowledged that the above form was executed by him or her.
Witness my hand and official seal, this the � day of , 20 AG
My Commission Expi s:
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STATE OF
COUNTY OF
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7 �,
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Notary PV6
OFFICIAL SEAL.
a
�y Pubto. NoM Ca►olnr
(SEAL) County of wake
NATALIE M. F�
My Commisson Expires
(additional financially responsible party)
I, , a Notary Public of said County and State, do
hereby certify that personally appeared before me this
day and under oath acknowledged reading the information above and acknowledged that
the above form was executed by him or her.
Witness my hand and official seal, this the day of , 20—.
My Commission Expires:
(SEAL)
Notary Public