NCC243001_FRO Submitted_20240926

r ATI IAM. . w:. s Land-Disturbing
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: Governors Club- Lot 857 DATE: 8-21-2024
ADDRESS OF PROJECT: 50134 Manly Chapel Hill, NC 27517
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.8503/-79.0430
PARCEL#(S): 69751
TOTAL DISTURBED ACRES or SQUARE FEET: .872 Acres
PURPOSE OF ACTIVITY: New single family construction
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: Bryan & Mary Jane Huth Phone: [phone]
Address: 1446 Honeysuckle Dr NE b anlhuth
E-Mail: rY @cs.com
Albuquerque, NM 87122 Bryan L. Huth Digitally70eadby Bryan LHuth
Signature: rY Date:�o24.oaz,,9:�,:z2-06 00
**FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner)
Name: Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Jason Dell Phone: [phone]
Address: 50051 Governors Dr Suite A anon
E-Mail: J @boldnc.com
Chapel Hill, NC 27517
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Arcadia Consulting Engineers Person to contact should erosion &sediment
Address: PO Box 2077 control issues arise during land-disturbing activity:
Apex, NC 27502
Contact Person: Deke Burch
Contact Person: Trent Stewart Company Name: BOLD Construction Inc
Phone:[phone] Phone: [phone]
E Mail: [e-mail] @boldnc.com
boldnc.com
E Mail:
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A 1 I A M " ' u N—rik...
Soil Erosion and Sedimentation Control
c. al K) I. ® N 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 parry(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: Bryan and Mary Jane Huth
Company(if applicable): Owners
Signature: Bryan L. Huth Digitally signed by Bryan L.Huth
Date:2024.08.21 19.22:33-06'00'
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title: Jason Dell
Company: BOLD Construction Inc
Signature:
******************************************************************
titt ktes42t r , a Notary Public of
( -4 County in the state
of ,t,.42, do hereby certify that flee.,,` ,4 ti Dell personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above f m as executed by him or her. p�
Witness y nd and official seal, this the Z4 Sit dayof >r\U i9.c. 20 2-A
Notary Public AFSHIN HOSSEINPOUR
NOTARY PUBLIC
My commission expires 1 '2 7 Oroagg Qq my
My Commission Expires
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