NCC243082_FRO Submitted_20241004

t
= 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 agreen ent signed byboth
parties must be provided allowing the financially responsible partyg
the property. person to conduct the land-disturbing activity on
PROJECT NAME: Lor 628 - Governorws Club
DATE: 8/6/2024
ADDRESS OF PROJECT: 12914 Morehead Chapel Hill, NC 27517
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.8455/-79.0469
PARCEL#(S}: 0068224
TOTAL DISTURBED:ACRES or SQUARE FEET: .514 acres
PURPOSE OF ACTIVITY: New single family residence
FEE AMOUNT SUBMITTED:
**LANDOWNERS OF RECORD attach a e to list additional owners
Please provide a complete list of partners, managing members and registered agents if the responsible entit or
land owner is a group of individuals, corporate organization or entity. y
Name: Dan & Kimberly Floss
Phone: [phone]
Address: 17359 Elk Drive E_Mai(: [e-mail]
Orland Park, IL 60467
Signature: :... o-kA � `.
*FINANCIALLY RESPONSIBLE PARTY a licable onl if different from ro ert owner
Name:
Address: Phone.
E-Mail:
Signature:
NORTH CAROLINA AGENT a licable onl if owner or financial) res onsible art does not reside'
North Carolina to
Name: Chris hrenfeld
Phone: [phone]
Address: 50051 Governors Dr ulte boldnc.com
Cha[pel Hill, NC 275 E Mail: [e-mail]
Signature:
ENGINEER/SURVEYOR
EROSION CONTROL
Company Name:
Arcadia Consulting Engineers
Address: PO Box 2077 Person to contact should erosion &sediment
Apex, NC 27502 control issues arise during land-disturbing activity:
Contact Person: — — — -- Contact Person: Les Clark
Trent Stewart
Phone:[phone] Company Name: BOLD Construction Inc
Phone: 9i9 2103596
E-Mail: [e-mail]
E-Mail: [e-mail]
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CH r is iA/VI UNTY
Soil Erosion and Sedimentation Control
N `I `� n `) ' ' 4 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 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: Dan & Kimberly Floss - Owners
Company(if applicable):
Signature:
�-��'
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title:
Company:
Signature:
NORTH CAROL AGENT if any):
Name and Title: ('
Company: .�.
Signature:
******************************************************************
,: e: ' :
tary lc f ou ty in the state
of (vim do by cy t-� U,u. 65S YJk personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above fo as executed by him or her.
Witness nd and official seal,this the day of 0
AFSHI TARP PUBLICOUR
NO TARN(County
Notary Publi Orange
North Carolina
My commission expires 'Z'27' My Commission Expires L)
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