NCC242848_FRO Submitted_20240920

CHATHAM COUNTY
N O i.T H C A R O L I N A
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
DEPARTMENT OF SOIL EROSION & SEDIMENTATION CONTROL
A Land-Disturbing Permit must be obtained before initiating any land-disturbing activity which
will exceed(1)acre (43,560 square feet). A Land-Disturbing Permit Application,this Financial
Form, an Erosion and Sediment Control Plan,plan review fee, and permit fee should be submitted
30 days prior to the planned commencement of the land-disturbing activity.
The above information should be submitted to: Jim Willis
Soil Erosion&Sedimentation Control Dept.
P.O. Box 130, 80 East Street
Pittsboro,NC 27312-0130
Pleaselye22r print the following information:
Date:
Name of Project: Chapel Ridge Lot 532
Location of Project: 1062 Cabin Creek Pittsboro, NC 27312
Acreage to be disturbed: 0.27
Purpose of activity: Build a single family home
Landowner(s) of record:
Name: Chamberlain Homes LLC Name:
Address: 120-A N Salem St Address:
Apex, NC, 27502
Telephone: Home Telephone: Home
Office 919.796.0953 Office
Fax Fax
E-Mail E-Mail
Indicate Book and Page where deed or instrument is filed.
1377 1172
Bo# 973400-14-3400 Page
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. 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. If the person financially
responsible is not a resident of North Carolina,a North Carolina agent must be designated. If someone
other than the owner is financially responsible,their signature is required below also.
Frank Barbee Name of individual
NC agent's signature (If applicable)
Owner/Manager
Title and Name of Company
Additional Financially Responsible
Party(If applicable)
Owner's Signature

?*
C 1--1ATi-IA /VI CouNTY
N () I !- I! (- A !t () I ! 1N A
*This section must be signed in the presence of a Notary in order to be r p ()Ce.SSed•*
PLEASE READ THE FOLLOWING INFORMATION:
All Land-Disturbing permits are valid for up to (2) years from the date of issuance. If circumstances warrant, the permit extended
per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Upon written notice, the tLand Disturbingpermit mayhe revoked for failure to comply with the Ordinance. If the permit is revoked, all other and approvals are withheldg
permitspp until the property is once
again in compliance with Chatham County regulations. Also, upon written notie, a civil penalty (tine) can he instigated against the property owner
and/or additional financially responsible violationsg g p p Y
p party (if any) for of the Chatham County Soil Erosion and Sedimentation Control Ordinance. This
penalty is up to S5000.00 per violation per day and is assessed daily for every day the property is in violation. Interferingwith or hampering an
inspection can result in a civil penalty without written notice. p g
The information provided on this form is true and correct to the best of my knowledge and belief and wasprovided byme while under oath.
g
OWNER OF PROPERTY: This form must be signed by thepropertyowner if an form must he signed by an officer, director, partner, attorney-in-fact, or otherperson with authority
individual. If owned by a company or corporation, this
y 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.
Name and Title: Y-._ Nit _- 3-E" 0 H -Ili
Company: C-1--irvtiv\I3Tr: V L--1--V ki. -A-tQ 4 --(- -- --- L___L... C____
Signature:
•- .
ADDITIONAL riz,
NANCIALLY RESPONSIBLE PARTY (if any):
:
Name and Title:
Company:
Si anature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
I, &UC? 0 GiikiWO)1/4k , a Notary Public of Count
y in the state
of1\j04- CVDU_vk_ �\......_ do hereby certify thatIcAel•-es.v son l
er
p a ly
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him or her.
C-�'t
Witness myhand and official seal, this the 1 day of , 2
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Notary Public 'r. NOTAR), S
M commission ex ires —‘i) 1 SEAL PUBLIC ? _
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