NCC243183_FRO Submitted_20241017

Soil Erosion and Sedimentation Control
CHAN HAM n." 14 v Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE 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 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.
3)This form must also be signed by the financially responsible party and NC agent(if applicable).Same provisions of#2 above apply.
4)If the landowner and financially responsible party are different,the completion and signing of this page shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land-disturbing activity on the
landowner's 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 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 redone Also,upon'oakum 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 55000.00 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: \�t
Name and Title: _TO NA M . nn V PC-CS om-
Company(if applicable):k(Yl_ FCC(-* BU\`ee(S, inC. DIsicl Dunn n CAA-1-r tklXr S
Signature:
FINANCIALLY RESPONSIBLE 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, t'1\2,1C lS 1�• 'PO 'ur ,a Notary Public of ChG (Inft
County in estate
of CUYo t rot do hereby certify that (hn M ."1)11t1"(1t0.9 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. rr1
Witness my hand and official seal,this the)�1 day of al 4` ,20 22
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Notary Pu is Notary �o i
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My commission expires 01— Q I Z�Zq (SEA My Chatham
u County
Expires Feb 4,2021
'age 3 of 3