NCC242191_FRO Submitted_20240719

DocuSign Envelope ID:93EC7A43-8782-45D6-9DE1-D42988ACCDDI
1,,,,„.„
_.�"A Land-Disturbing
(2t A %k. NL. ( l I S N 3 Permit Application
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: [phone]
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 in acres 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 pattern(s)on sheet 1 of the Residential General Plan.
❑ Residential Lot Permit. The following items are required to obtain this permit: completed
application(if required, see note 4 on PERMITTING FLOW CHART), site plan, and fee.
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

DocuSign Envelope ID:93EC7A43-8782-45D6-9DE1-D42988ACCDD1
Land-Disturbing
5 = Permit Application
PROJECT NAME: ()31700 5 eeS( donce DATE: "7 ar
ADDRESS OF PROJECT: 3F57 85hley 10000(5) 51"ler k li(� e913Y
LATITUDE/LONGITUDE OF PROPERTY AT!SITE ENTRANCE: 3'5, 7 6-5 7 50 / i 9, 3 -7 09(�
PARCEL#(S): (0 -la,
TOTAL DISTURBED ACRES or SQUARE FEET: f, I a e N' ,
PURPOSE OF ACTIVITY: 111,CU` c7efri ff�r c 1 Ui
FEE AMOUNT SUBMITTED: /WO
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: 5cA t'1C 7 C`S .,UJSiS[ Phone: Ja(.`a " r�l,�"� l c�.S
Address:c U f( �✓19(� tva � /� F✓ E-Mail: s ydw r 1-foi.t). , )(.0 i a.ll cry, ioi�,v)
Pl f f-s�wic)/ 0 tri' d-731 Signature: �° !o°4'°V°�,
4CBA8CEE578045D..
FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner)
Name: ycJC (U�l5rrd 1�. 1G�.'' ASV , f Phone: Cif' t L( > 3 t( c4"
Addr s:: I' ( t' G(c,�re JJ Pr
E-Mail:/A' 4f� f J t S FOLIC .V1 (` Gr..,k1C%tfrL �.C44-
i (dUVO) a1C:, &- 13 1,4 Signature: /l.. ,{,,7
NORTH CAROLINA
AGENT(applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR 9 EROSION CONTROL
Company Name: Gci(ici/ LaK S aillSta-Gp Person to contact should erosion &sediment
Address: / WO Ol i V - control issues wipe during land-disturbingactivity:
A-ppy1 Oa- Contact Person: ,5K
Contact Person, {'Je.'V1\/ I G�\// / Compan�j'Name: ! 1j_cotiitA. �Gb?,c!Gd U�1 '� U, �L�✓'
Phone: e l f �O I i ()� Phone: (1// '.+ q 3 cf g(
E Mail P v` wi GO'fax/ �(Jc� I C. COW E-Mail: MSCirt)�'�C2d sfc4 1 v1 MS-hac
Page 2 of 3

DocuSign Envelope ID:93EC7A43-8782-4506-9DE1-D42988ACCDDI
' `— Soil Erosion and Sedimentation Control
C�HA I-1A2\4 CCMINTY
" '° ' " ' A 't" ' ,' Financial Responsibility/Ownership Form
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:
Sandra Ostrowski
Company • Ml A y
as a om,,w,V,
Signature:
4CBA8CEE578045D...
ADDITIONAL FI ANCIALLY RESPONSIBLE PARTY(if any):
Name and Title: A so,/ t �j(,{ j/t�a l�
Company: fib SC)I c; COr�Sel..te (49 4e- Y 10 tryf° fru e 1 I
Signature: i�t,/��,
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
********%F%k``%k�k�k�k*�k�k�k�k****�k*=K�k�k=k�k�1=�k�:e�k�k�k****�k�=�k=k�k-k****- **************
I,lP. a �`l W h ,a Notary Public of // � Q,� County in the state
of e- •
do hereby certify that CA 6a. JL?kin pl .� personally
appeared before me this day and under oath acknowledged reading the information abovvand acknowledged that the
above form was executed by him or her.
Witness my hand and official seal,this the 'l day of J.UJ(t. 20014
Notary Public 1 ( __--- °--�` Deborah NI Brown
`-F;
My commission expires O - . Ma`7 r„F (S�Ry I�UBLIC
`4 ) Lee County,NC 2024
�v�,or,cnleeion Exp
Ire October 04,
Page 3 of 3