NCC231206_FRO Submitted (2)_20230426

SoIlll Erosion and Sedimentation Controi
Cf./AI'ifrA C7(1.1 IN-t 1! Financial'
r� n6�1❑I FORM
'ti tJ It 8 i6 i. A R di d E A. h Ii iii arntciall Responsibility/Ownership ll ORM
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I)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 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 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#2 above apply.
4)If the landowner and financially responsible party are different,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 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 he 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.
OWNER OF PROPERTY:
Name and Title: Christopher`Edwar Hurdle& Broolg‘idie Hurdle
Company(if apphcablsv Signature: _ y
Signature: 4v1 '{ ' .. arr¢� ° � : .._.
FINANCIALLY RESPONSIBLE ARTY(applicable only if different from property owner):
Name and Title: Richard Gephart- Manager
Company: Ge hart Building Company
Signature:.__,
NORTH CAR LINA AGENT(if any):
Name and Title: n/a
Company:
Signature:
*=k*******%k******3=*******=1:****%k****-F***********%k***%k%k*****=ka=*******
e ,a NotaryPublic of R
-d`; �c r��' Co wnty in the state,
of N ( do hereby certify that (2.ki .l t �>l��r �:r<-:.r �"a o e 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 u' �e � 20 3
K Qt, %D
Notary Pul5i E U�
My commission expires 0` if'' ('L let 2 7 6 (SEAL)
01
Page 3 of 3 �'4004aeouiliso°p°

************************
-TWA'I��, kee%5 , a Notary Public
of bat', e, County in the
state of , do hereby certify
that r 6<_p iie,A.4—
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
/.44,61-, , 202/.3
Notary Public
My commission expires JAWWAD TAALIB EVANS
Pa NOTARY PUBLIC
l� v'�a/1 .1 6 Wake County
North Carolina
My Commission Expires Dec.28,2026
Page 4 of
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