NCC243055_FRO Submitted_20241002

Soil Erosion and Sedimentation Control
c1 InIrf O 4 A 44»<INA'l' Financial Responsibility/Ownership Form
NOT REQUIRED 70 BE Cal/l'LETE1)FOR RE.SIDEVTL I L 1.U7'l'l:RA1/7S.
PLEASE READ '1.1IE FOLLOWING INFORMATION:
i)This section must be signed in the presence of a Notary.
2)This form must be signed by the property owner if an individual.If owned by a company or corporation,this form must he 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.
3)This form must also be signed by the financially responsible party and NC agent(if applicable).Same provisions of d 2 above apply.
4)if the landowner and financially responsible party arc different,the completion and signing of this page shall serve as documentation
acknowledging the landowner consents to and authorises the financially responsible party to undertake the proposed land-disturbing activity on the
landowners tract(s)of land identified on this application.
5)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.
6)All Land-Disturbing permits are valid for up to(2)years from the date of issuance. If circumstances warrant, the permit may he 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 he 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.
OWNER OF PROPERTY:
Name and Title: Shawn Zavoda, Owner
Company(if applic e): N/A
Signature: U
FINANCIALLY RES NSIBLE PARTY (applicable only if different from property owner):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT(if any): •
Name and Title:
Company:
Signature:
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I, 14?\\��t�able ,a Notary Public of Una\\nryrv\ County in the state
of l o�t\n C cu r t vl•. do hereby certify that_ C10.N O rr 2..Gv Oc\ personally
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.
Witness my hand and official seal,this the k '' day of____ RN , .
Y_OS:9.1kirYlik61 114
Notary Public Kelly McNabb�gt.IC
My commission expires 1-1ti�l2lo (SEAC�� 01 ARse County
No Garonne 2i 2026
MY
missbn Expltes February
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