NCC231423_FRO Submitted_20230512

Land-Disturbing •
Ci T MC , .
tl A Of> s r4 A 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. box is NOT acceptable as an address.
**If the financially responsible person/party is different from the current land owner,an agreement signed by both
parties must be provided allowing the financially responsible party person to conduct the land-disturbing activity on
the property.
PROJECT NAME: 1187GC-Lot 1187 Governors Club DATE: 2/21 t23
ADDRESS OF PROJECT: 10388 Holt
LA ITI'UDEILONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.84841-790502
PARCEL#(S): 72051
TOTAL DISTURBED ACRES or SQUARE FEET: 25000
PURPOSE OF ACTIVITY: New single family residence
FEE AMOUNT SUBMITTED:
................................... .................... ... ....
**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: Rafael&Rosa Seer Phone: [phone]
Address: 2901 S Bayshore Dr Apt 17G E-Mail: rs - • «.•--;r••
Miami, FL 33133 ,� 1111
Sig tore tt)► / . lF
**FINANCIALLY RESPONSIBLE PARTY (applicable only if di ere property owner .1
Name: Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT(applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Sheen Hosseinpour Phone: 919 92•:6288
Address: 50051 Governors Dr Suite A E-mail: sheens: ►.Idnc.com
Chapel Hill, NC 27517 Signature: -a
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Arcadia Consulting Person to contact should erosion&sediment
Address: PO Box 2077 control issues arise during land-disturbing activity:
Apex,NC 27502 Contact Person: Tim Dowds
Contact Person: Trent Stewart Company Name: BOLD Construction Inc
Phone:[phone] Phone: [phone]
E Mail: [e-mail] E_Mail: [e-mail]
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+BHA ur
Soil Erosion and Sedimentation Control
Financial Responsibility/Ownership Form
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)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 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 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.
3)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.
4)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.
OWNER OF PROPERTY:
Name and Title: Rafael&Rosa Saer
Company(if applicab .
Signature:
ADDITIONAL FINAN SPONSIBLE PARTY(if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AG NT (if any): r
Name and Title: , 2AA, 416 Company: C �LtVOW.
+,
Signature:
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I l t. ,a Notary Public of crItt County in the state
of f V t v►q do hereby certify that u personally
appeare fore me this day and under oath acknowledged reading the information above and acknowledged thatthe
abov o was executed by him or her. �_(r',,�'J
Witne hand and official seal,this the c et
day of AC< ,20 23
AFSHIN HOSSEINPOUR
Notary Pu c NOTARY PUBLIC
My commission expires ' .•'2j Or unty
N crbling
My Commission Expires t 7 Z9.
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