NCC230901_FRO Submitted_20230331

CHATI-IAM CQUN-rY
Nei R T H CAR" L INA
Land -Disturbing
Permit Application
**The mailing 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. bog 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 land -disturbing activity on the property.
This agreement is provided on page 3 of this application and must be completed in its entirety.
PROJECT NAME: Cora Lane Farm House
ADDRESS OF PROJECT: 33 Cora Ln Pittsboro, NC 27312
DATE: January 16, 2023
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.669602,-79.219282
PARCEL #(S): PARCEL: 6397, PIN:9639-00-58-4329
TOTAL DISTURBED ACRES or SQUARE FEET: 44,248SF
PURPOSE OF ACTIVITY: HOME CONSTRUCTION
FEE AMOUNT SUBMITTED: $600 RIVER BASIN: CAPE FEAR
**LANDOWNER(S) 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: Claire Apple Phone: [phone]
Address: 124 Guthrie Road E-Mail: [e-mail]
Pittsboro, NC 27312 Signature: L-
"FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
N, ne: Margaret E. Viverito Phone: [phone]
Address: 512 E. Amelia St. E-Mail: magsv36 Q Mail
Orlando, FL 32803 Signature:
NORTH CAROLINA AGENT (applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Anna Wirth Phone: [phone]
Address: 909 N 7th STreet
Mebane, NC 27302
ENGINEEWSURVEYOR
Company Name: David Cates Consulting PLLC
11,11F.100,15RUM $,To] ia" �
EROSION CONTROL
Person to contact should erosion & sediment
Address: 210 S Wake St Hillsborough, NC 27278 control issues arise during land -disturbing activity:
Contact Person: Anna Wirth
Contact Person: David Cates
Phone: [phone]
E-Mail: [e-mail]
Company Name: Flock Design and Architecture, pllc
Phone: [phone]
E-Mail: [e-mail]
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ANTICIPATED START DATE: January, 2023 ANTICPATED END DATE: July, 2023

��- Soil Erosion and Sedimentation Control
�i I I I I� Y Financial Responsibility/Ownership Forin
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS
PLEASE READ THE FOLLOWING INFORMATION:
1) This section must be signed in the presence of a Notary.
2) This form must be signed by the property owner if an individual. If owned by a company or curporation, this form must be signed by an officer,
director, partner, attorney -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.
3) This form must also be signed by the financially responsible party and NC agent (if applicable). Same provisions of tl 2 above apply.
1) If the landowner and financially responsible party are dillerent, the completion and signing of this page shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land -disturbing activity on the
landowner's tract(s) of land identified on this application.
5) 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.
6) All Land -Disturbing permits are valid for up to (2) years fi•om the date of issuance. If circumstances warrant, the pen -nit may be extended for
(2) years per the conditions of the Chatham County Soil Erosion and Sedimentation Conuol 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 arc 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 arty) 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 ttte property is in violation.
Interfering with or hampering an inspection can result in a civil penalty without written notice.
OWNER OF PROPE�RJTY:
Name and Title: _S ' /�" ��'n
Company (if applicable):
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title: f PARMF_VT V1 Ut2 1 U
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title: Anna Wirth- Owner
Company: Flock Design ang AKhiitecture, pllc
1-1
Signature:
*************>k*=k*>l *).14**************=k* ********ac****>k******=<=k*X*>k****
L,,, / , a Notary Public of County in the state
of 1� •1,6— do hereby certify that C I h.'vA. M VnNII personally
appeared before me this day and under oath acknowledged reading the informa ion above and acknowledged that the
above form was executed by him or her.
Witness m hand and official seal, this the day of 1 a0 Z
y HO
=4T 0-1 AR y
Notary Public - \
My commission expires 3 ( ?'iO 2 pU) _`
1/4 NA M c0�,` '\
till\%\
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