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HomeMy WebLinkAboutNCC232193_FRO Submitted_20230725 Land-Disturbing CI IATIIANI CC-MINTY Permit Application V l! N I N t o It e/ ! IN A Please complete both pages of this form and return to: For Office Use: Physical Address Mailing Address 80 East St. PO Box 548 Pittsboro,NC 27312 Pittsboro,NC 27312 Phone: (919)545-8268 Please see PERMITTING FLOW CHART to determine which permit and plan requirements apply to your project and then check one of the boxes below: ❑✓ Land-Disturbing Permit. The following items are required to obtain this permit: completed application, plans, and fees. Land-Disturbing Permit applications must include all parcels/lots on one application with the total amount of disturbance for all parcel/lots. All clearing and disturbance must be included when calculating disturbed area. Fee Requirements: Permit Fee: $250/disturbed acre Plan Review Fee: $250/disturbed acre Fees are rounded up to the next whole acre. Example: 1 acre or less is $500, 1.01-2 acres is $1,000, and 2.01-3 is $1,500. Plan Requirements: Design Plan: submit(1)copy of an erosion control plan completed& sealed by a professional land surveyor, professional engineer, or registered landscape architect. This plan must meet the criteria of the Chatham County Erosion Control Plan Review Checklist and include all applicable construction details. These can be found on the Chatham County Watershed Protection website, on the Erosion Control webpage. This plan must satisfy all local, state, and federal minimum plan requirements. General Plan: submit(1) copy of site plan along with the Chatham County Residential General Plan. Site plan is not required to be completed by a design professional. The Residential General Plan can be found on the Chatham County Watershed Protection website on the Residential Construction webpage. Indicate lot drainage patterns) on sheet 1 of the Residential General Plan. El Residential Lot Permit. The following items are required to obtain this permit: completed application, site plan, and fee. PAGE 3 "FINANCIAL RESPONSIBILITY/OWNERSHIP FORM" not required. Fee Requirements: Plan Requirements: $100 flat fee Site Plan showing property boundaries. The site plan required by the Environmental Health or Central Permitting Departments is sufficient. ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY Page 1 of 3 Land-Disturbing C I IA�TI I A Ai Cc n INTI Permit Application l t **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: Lot 7 Hills of The Haw DATE: 5/30/23 ADDRESS OF PROJECT: 150 Haw River Trail Pittsboro, NC 27312 LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.725/-79.099 PARCEL#(S): 17309 TOTAL DISTURBED ACRES or SQUARE FEET: -98 PURPOSE OF ACTIVITY: New Single Family Dwelling FEE AMOUNT SUBMITTED: $500 **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: Eric Schwartz& Melissa Grahn Phone: 919-636-2020 Address: 229 Keythorpe Ln Cary, NC 27519 E-Mail: ericschwartz8185@gmail.com Signature: r **FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner) Name: Phone: Address: E-Mail: Signature: NORTH CAROLINA AGENT japplicable only if owner or financially responsible party does not reside in North Carolina) Name: Phone: Address: E-Mail: Signature: ENGINEER/SURVEYOR EROSION CONTROL Company Name: Smith&Smith Surveyors, P.A Person to contact should erosion & sediment Address: P.O. Box 457 Apex, NC 27502 control issues arise during land-disturbing activity: Contact Person: Nolan Poythress Contact Person: Ben Smith Company Name: Poythress Construction Company Phone:919-362-7111 Phone: 9198106087 E-Mail: ben@smithandsmithsurveyors.net E-Mail: nolan@pccbuilder.com Page 2 of 3 Soil Erosion and Sedimentation Control C'H.A"ii SHAM C- tir i'v 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: Eric Schwartz& i1Meissarahn, Landowner Company(if a�licable):�� Signature: ADDITIONAL FINANCIALLY RESPONSIBLE PARTY(if any): Name and Title: Company: Signature: NORTH CAROLINA AGENT(if any): Name and Title: Company: Signature: ****************************************************************** I,gAk,'- ‘,/,00. / ,a Notary Public of ,� � County in the state of 01') 5/1c do hereby certify that f ri C /e017P 5r4/0c/e personally appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe above form was executed by him or her. Witness my hand and official seal,this the 3/ day of No ,20 Zi3 war.Jos .s Falgunibahen A Patel Notary Public a ` ' Notary Public, North Carolina � ,`` EAY., e County k My commission expiresc V1 —5 Z©Z� ( ' - ` y Co mission Expires January 5, 2027 Page 3 of 3 Soil Erosion and Sedimentation Control CiiATTHAit COUNTY 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: Iik e i t SS a Card t" Name and Title:- 4-iG--SP-14wagt41 Landowner Company(if pp licable Signature /f ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any): Name and Title: Company: Signature: NORTH CAROLINA AGENT(if any): Name and Title: Company: Signature: ****************************************************************** II rr11 � ,a Notary Public of County in the state of NO(Ain 00-0I in CA do hereby certify that Me,t iSSQ C YO VW\ personally appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe above form was executed by him or her. Witness hand and official seal,this the 1 S� day of A)It I°1 ,202 Perla Ucles No Public ate NOTARYWake C PUBLIC,Northounty Carolina rr��,,cVL�� ` My c mmission expires NO fI' .�' jr • tgEt.Unmission Expires • November 18, 2025 Page 3 of 3