NCC231046_FRO Submitted_20230505

Orange County Planning 8 Inspections Department
ORANGE w,GE COUNTY TY 131 W. Margaret Lane, Suite 200, Hillsborough, NC 27278
NORTH CAROLINA 919-245-2575 or [e-mail]
Land Disturbance Permit (LDP) Application
Please refer to instructions and checklist in completing the following application.
If completing by hand,please use black or blue ink.
Date: 02/06/2023 Case Number:
Check all that apply: E✓ Erosion Control Plan
QStormwater Permit
Stormwater Management Plan
General SubmittalInformation
Name of Project: Three Creeks
Parcel ID Number(PIN): 9876028869 Planning Jurisdiction: Orange County
Size of Tract 15.06 acres Area Disturbed 1.692 acres
Section completed by Stafigi
Fee Amount
Erosion Control Plan Revllew
Required with App!Ientkm
Land DisturbIN Print
Optional with Initial Applie 'o $
Stormwater Management Plat- ' c v
Orange County Planning Jurisdir.Vs t Only
Required with Applic ;tior:
Total $
Approximate date land disturbance will begin:
contact Information
Landowner(s) of Record (Use additional pages if necessary and attach to application):
Name: Thomas Nechyba & Kristen Orgera Name:
Street Address: 872 Three Creeks Road Street Address:
Hillsborough NC 27278
Current Mailing Address: 2719 McDowell Road Current Mailing Address:
City: Durham City:
state: NC Zip: 27705 State: Zip:
Phone: NAP` Phone:
Email: N/A Email:
Page 1 of 4

Contract Purchaser(if applicable)(Use additional pages if necessary and attach to application):
Company/Organization: Company/Organization:
Contact Person: Contact Person:
Street Address: Street Address:
Current Mailing Address: Current Mailing Address:
City: City:
State: Zip: State: Zip:
Phone: Phone:
Email: Email:
Person(s) or Firms) Financially Responsible for this Land Disturbing Activity:
Company/Organization: Thomas Nechyba Company/Organization:
Contact Person: Thomas Nechyba Contact Person:
Street Address: 872 Three Creeks Street Address:
Hillsborough NC 27278 - _
Current Mailing Address: 2719 McDowei: Road Current Mailing Address:
City: Durham City:
State: NC Zip: 27705 State: Zip:
Phone: [phone] Phone:
Email: [e-mail] Email:
Registered Agent(if any) for the Person(s) or Financially Responsible Party:
(NOTE:a North Carolina agent is required if the applicant is not a resident of North Carolina)
Name: Collins Design-Build, Inc. Name:
Street Address: PO BOX 2915 Street Address:
Durham NC 27715
Current Mailing Address: PO BOX 2915 Current Mailing Address:
City: Durham City:
State: NC Zip: 27715 State: Zip:
Phone: [phone] Phone:
Email: [e-mail] Email:
Page 2 of 4

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Additional Projectlnformatfon
Project Description (detail the scope of the project and nature of land disturbance):
Single family residence: the Nechyba/Orgera project is 15.06 acres. Currently the site is about 100%
wooded. The proposed development will include clearing for the installation of a driveway, house, shop,
pool/deck and garden area.The project is located in the Falls (Neuse)Watershed.
Plans Prepared by:
Name of Person/Firm: David E Cates PE
Contact Person: David Cates
License Number: 16272
Mailing Address: 210 Soouth Wake Street
City: Hillsborough State: NC Zip: 27278
Phone: [phone] Email: [e-mail]
Page 3 of 4

•
Certification and Signatures II-
Signature and Witness: The above information is true and correct to the best of my knowledge and
belief and w s provide by me while under oath.
�� hoivccS /Uec/t fbc1
Signature of mancially Responsible Party Type or Print Name Legibly
Titlggo�r uthori�t� Date
I, f4i' ) 4JW1 ie5' 4 a Notary Public of the County of .-4i4f/ A/e
hereby certify that 1140444.25 ei• e 4 ig • - personally before me this day and
under oath acknowledged that this 661ication for Erosion Control Plan Approval, Stormwater
Management Plan Approval, and Land Disturbing Permit I Statement of Ownership and Financial
Responsibility was executed by him or her.
Witness my hand and notarial seal, this 6O4�Day of 1`4141' , P9.2?
(Oe,c, 9 * „?02,2 /6-6
Signature of Notary 4-pk: q____ _
My Commission Expires c-,tl t .r r,1 sill, ' ,
t*r: 4, 'i
SEAL =`:Ni F,\ / •
e. F •• 4 i s •
Property Owner Acknowledgement ; r - 4- r► ,,
I hereby acknowledge the above information and parties referenced herein have been gr_ s•'/. c - ,`
permission to conduct development activity on referenced property of which I own. cd ' •
hcxMai /Jicfy& --
S" nature of erty Owners Type or Print Name Legibly
*6,51011
Date "-_I, e a Notary Public of the County of ���1 /�hereby certify 40o-45 Wet1 t personally before me this day and ;
under oath acknowledged that this Ap cation for Erosion Control Plan Approval, Stormwater -•
Management Plan Approval, and Land Disturbing Permit I Statement of Ownership and Financial
Responsibility was executed by him or her.
Witness my hand and notarial seal, this fob Day of 5/tQ , ,o0�3
its,4* -ilt 6/i,'/?et. -1 20,7.1. l ,2
Signature of Notary My Commission Expires /
SEAL
-�' Page 4 of 4