NCC215681_FRO Submitted_20211013

C14AXI [AM C01UP T"Y
N" R T H CA R" L 1 N A
Land -Disturbing
Permit Application
Please complete both pages of this form and return to: For Office Use:
Physical Address Mailing Address
80 East St. PO Box 548
Pittsboro, NC 27312 Pittsboro, NC 27312
Phone: [phone]
Please see PERMITTING FLOW CHART to determine which permit and plan requirements apply to
your project and then check one of the boxes below:
❑ Land -Disturbing Permit. The following items are required to obtain this permit: completed
application, plans, and fees. Land -Disturbing Permit applications must include all parcels/lots on
one application with the total amount of disturbance for all parcel/lots. All clearing and disturbance
must be included when calculating disturbed area.
Fee Requirements:
Permit Fee: $250/disturbed acre
Plan Review Fee: $250/disturbed acre
Fees are rounded up to the next whole acre.
Example: 1 acre or less is $500, 1.01-2 acres is $1,000, and 2.01-3 is $1,500.
Plan Requirements:
Design Plan: submit (1) copy of an erosion control plan completed & sealed by a professional land
surveyor, professional engineer, or registered landscape architect. This plan must meet the criteria of the
Chatham County Erosion Control Plan Review Checklist and include all applicable construction details.
These can be found on the Chatham County Watershed Protection website, on the Erosion Control
webpage. This plan must satisfy all local, state, and federal minimum plan requirements.
General Plan: submit (1) copy of site plan along with the Chatham County Residential General Plan. Site
plan is not required to be completed by a design professional. The Residential General Plan can be found
on the Chatham County Watershed Protection website on the Residential Construction webpage. Indicate
lot drainage pattern(s) on sheet 1 of the Residential General Plan.
❑ Residential Lot Permit. The following items are required to obtain this permit: completed
application, site plan, and fee. PAGE 3 "FINANCIAL RESPONSIBILITY/OWNERSHIP FORM"
not required.
Fee Requirements:
Plan Requirements:
$100 flat fee
Site Plan showing property boundaries. The site plan required by the
Environmental Health or Central Permitting Departments is sufficient.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

Land -Disturbing
C1 1ATI III L"urFW A Permit Application
11 [1 H I I l A it c1 11 Fi A
**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: Westfall Lot 111
DATE: 7/27/21
ADDRESS OF PROJECT: 122 West Beech Slope Ct., Chapel Hill, NC 27517
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.8271/-79.0556
PARCEL #(S): 93555
TOTAL DISTURBED ACRES or SQUARE FEET: 0.54
PURPOSE OF ACTIVITY: New SFD
FEE AMOUNT SUBMITTED: $500.00
"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: Westfall Associates Phone: [phone]
Address: 128 Yorkchester Way E-Mail: [e-mail]
Raleigh, NC 27615 Jan Futrell Digitally 7.27 an Futrell
g Signature: Date: 2021.07.27 14:53:04-04'00'
"FINANCIALLY RESPONSIBLE PARTY (qpplicable only if different from property owner)
Name: ICG Homes, LLC Phone: [phone]
Address: 4020 Wake Forest Rd. Ste. 306 E-Mail: [e-mail]
Raleigh, NC 27609 g Ryan Perry Daietal2021.07277y1453 Ryan 8e-04'00'
g Signature:
NORTH CAROLINA AGENT (applicable only if owner or financially responsible party does not reside in
North Carolina)
Name: Phone:
Address: E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Taylor Land Consultants, PLLC
Address: 1600 Olive Chapel Rd. Suite 140
Apex, NC 27502
Contact Person: Jeremy Taylor
Phone: [phone]
E-Mail: [e-mail]
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: Ryan Perry
Company Name: ICG Homes, LLC
Phone: [phone]
E-Mail: [e-mail]
Page 2 of 3

Soil Erosion and Sedimentation Control
Financial Responsibilite-/Oi� nership Form
N0T1?A;OC/1111:1> 10) Bj; ('U:1 J!'1l)1•'01?
PLEASE READ THE FOLLOWING INFORNIATiW
I ) This section must be sigticd in tau; prescncc of a Notan
i All Land-Distnfiing permits are valid for up to (?) Nears from file dale of issuance. If circum�,t;,nces i\-arrmt. tlae permit nla% be
extended for (2) \-cars per file co»ditions of the Chatlann Counts Soil Erosion and Sedinacnt;uion Control Ordinance. Upontsritten
notice, the Land-Dislurbing permit mas be revoked for failure to comph x\-ith the Ordiruttice. if the permit is revoked. all other
permits and approNals are aitlihcld until the propert\- is once main in compliance faith Chatham CouutN regulations. Also. upon
x%rittell notice. it civil pcnalh (Zinc) can be instigated against the propem o%\-ner and/or additiomil 17nanciall� responsible parr (if ens)
for \-iolations of the C'halhana COnratN Soil Erosion and Sedimentation Control Ordinance. This peiaiallN is tap to 'i0 oo.00 per \iolation
per da} and is assessed daily for everN da% the proper(\- is in violation. Interfering \\ ith or hampering an inspection can result in a civil
pcnalts t1 ithotrt isritien notice.
a Tile infonnafion provided on this fonn is inre and correct to the best of nn knowledge and belief and was provided b\- nee chile
under oath.
4 ) This fonn must be signed b� the properl\ ONVIler if an indi\idu al. If oisned b\ a conlpam or corporation, this form must be signed
b\- an officer. director. partner. attorney -in -fact, or other person iAilh authority to execute instnuncnts for the corporation and
accompanied b} a complete list of all par(r><rs, managing members and registered agents of the conapam orcorpomtion.
OWNER OF PROPERTY:
Nanlc and Title Jan Futrell, Manager
- --------- --- ---
Conlpan��licablc) Westfall Associates
Signature:
ADDITIONAL FINANC'IALI.N
Nanle and Tit!, Ryan Perry, Owner
Compam : ICG Homes, LLC
Signature:
RESPONSiISLE PARTY (if any):
NORTH CAROLINA AGENT(ifaft\-):
Name and Title:
CAnl pail \.:
Sig,nature:
4.:{X?;\X7j.'vvy..�:X:,:
1. Holly W. Brazell a Notar\ Public of Wake Count\ in the statc
,)f North Carolina do licrebv certih- that Jan Futrell personally
appeared before tile this day and under oath acknonledged reading the infornlation above and acknrnNl d«cd th:attLr
abocc form \\as e%ccutcd b\ him orher. ,,,
27th W , g
Witness nn hand and official seal. this the day of JulY 2021
Notar-, Pub is _
\1\ Commission c\l)ires 08/21/21 0130
'4,,,COU11N
n___ o _t -1

Soil Erosion and Sedimentation Control
Financial Responsibility/Oi` nership Form
V'0%'Il/•;O1 '11U..)
PLEASE READ THE FOLLMVi\Ci i\FORMATION:
I ) This sect loll Inust be signed in 111C presence of it NolarN
�) All Larxi-Disturbing permits arc Valid for up to (2) tears from the date of issuance. If circumstances currant. the permit maN be
extended for (2) Nears per the conditions of the Chatlialll ConnIN Soil Erosion and Sedimentation Control Ordinance. Uponnritten
notice. the Land -Disturbing permit maN be rooked for failure to comply with the Ordilklrlce. If the pennit is rc\okcd. all other
permits and approvals are %aithllcld until the propert\ is once agilin in conlpliallcc "'ith Chadim" County reg a ritten notice. a ci\ it pcnalt} (fine) can be instigated against the propene owner and/or additional linanciall\ responsible rms(ifurpon
for violations of the C'halham Counh Soil Erosion ind Sedimentation Control Ordinance. This pcnalt� is up to auu.ru► per iolation
per da} slid is assessed daily for c\en d;l} the properlc is in Violation Interfering kith or hampering an inspection can result in a civil
pcnall� I%ithoul X\rinen notice.
I) The information pro\ ided on this form is tree and correct to file best of nn kno\\ ledge and belief and mas provided be the while
tinder oath.
4) This fonn must be signed b% the proper\ 01%tier if an indh ideal. If o\\ tied b% a conlpam or corporation. this form must be signed
by an officer, director, partner. attonle\-in-tact. or other person kith aut}lorih to execute instruments for the corporation slid
accompanied b} a complete list of all partners. nuanagim members and registered agents of the conlpam orcorporltion.
OWNER OF PROPERTY:
Name and Title: Jan Futrell, Manager
Compam (if applicable) Westfall Associates
Signature
ADDITIONAL FINAN('11AL.LY RESPONSIBLE PART) (cram ):
Name and Title Ryan Perry, Owner
C
NORTH CAROLINA AGENT (if aiiy):
Name and Title.
Company
Signature:
I Holly W. Brazell
of North Carolina
Wake
Count\ in the state
�rsonallv
appeared before me this day and under oath acknowledged reading the infornation above and ackno\xlcdlocd thatthe
abo\e form \�a: �\Qcuted b\ him or her.
_. a Notary Public
do hereb, certiR tl
Witncss im hand and official seal. this the 27th da`. of July
Notary 13116
u i
M-% commission expires 08/21/21
Ryan Perry
2021
(SEAL)