NCC242100_FRO Submitted_20240715

Orange County Planning & Inspections Department
ORANGE COUNTY 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.
* Please fill out all required fields
Date: Case Number:
Check all that apply: n Erosion Control Plan
n Stormwater Permit
Stormwater Management Plan
General Submittal Information*
Name of Project: EYRING RESIDENCE
Parcel ID Number (PIN): 9856037743 Planning Jurisdiction: Orange County
Size of Tract: 5.00 acres Area Disturbed 1 .78 acres = 77, 493 sq.ft.
Fees — Section Completed by Staff
Fee Amount
Erosion Control Plan Review
Required with Application $
Land Disturbing Permit
Optional with Initial Application $
Stormwater Management Plan Review
Orange County Planning Jurisdiction Only
Required with Application $
Total $
Approximate date land disturbance will begin: August 2024
Contact Information*
Landowner(s) of Record (Use additional pages if necessary and attach to application):
Name: Henry Eyring Name:
Street Address: 2360 Halls Mill Road Street Address:
Current Mailing Address: 423 Flat River Run Current Mailing Address:
City: Hillsborough City:
State: NC Zip: 27278 State: Zip:
Phone: (801 ) 376-8201 Phone:
Email: [e-mail] 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 Firm(s) Financially Responsible for this Land Disturbing Activity:
Company/Organization: n/a Company/Organization:
Contact Person: Henry Eyring Contact Person:
Street Address: 2360 Halls Mill Road Street Address:
Current Mailing Address: 423 Flat River Run Current Mailing Address:
City: Hillsborough City:
State: NC Zip: 27278 State: Zip:
Phone: (801 ) 376-8201 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: Name:
Street Address: Street Address:
Current Mailing Address: Current Mailing Address:
City: City:
State: Zip: State: Zip:
Phone: Phone:
Email: Email:
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Additional Project Information*
Project Description (detail the scope of the project and nature of land disturbance):
Single Family Residence
Plans Prepared by:
Name of Person/Firm: Veteran Engineering Associates, Inc. (C-3527)
Contact Person: Thomas R. Kagarise, P.E., President
License Number: 011622
Mailing Address: PO Box 1625
City: Durham State: NC Zip: 27701
Phone: [phone] Email: [e-mail]
Page 3 of 4

Certification and Signatures*
Signature and Witness: The above information is true and correct to the best of my knowledge and
belief and was provided by me while under oath.
Henry Eyring
Signature of Fina ci ty Responsible Party Type or Print Name Legibly
Individual 9 /Q / 9
Title or Authori Date
I Mrc`11',1� Z.7vav1cl a Notary Public of the County of ��t li- L�Ke
hereby certifat Henry Evrinq personally before me this day and
under oath acknowledged that this Application for Erosion Control Plan Approval, Stormwater
Management Plan Approval, and Land Disturbing Permit/Statement of Ownership and Financial
Responsibility was executed by him or her.
Witness my hand and notarial seal, this 1'Day of Arri I , Z.OZ
C)7/o-7 /Q 1
Signature of No My Commission Expires
MALLORYCRANDAU.
1 es Nolary Public-Sfafe of Utah
r,. Commission 0 732021
"i ; AMC00110issimExpinn
SEAL ,_• July 7,2027
Property Owner Acknowledgement*
I hereby acknowledge the above information and parties referenced herein have been granted
permission to conduct development activity on referenced property of which I own.
Henry Eyring
Sign ture roperty Owners Type or Print Name Legibly
/1 /�1 �1
Date
i N1 i C yottnd ca I I a Notary Public of the County of SR 1-4-
hereby certifyhat Henry Evrinq personally before me this day and
under oath acknowledged that this Application for Erosion Control Plan Approval. Stormwater
Management Plan Approval, and Land Disturbing Permit/Statement of Ownership and Financial
Responsibility was executed by him or her.
Witness my hand and notarial seal, this q "Day of tpvt 1 ,
01 107 /
Signature of No My Commission Expires
MALLORY CRANDALL
SEAL / am; Notary Public"State of Utah
• /41 Commission II732021
My Commission Expires
July 7,2027
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