NCC221812_FRO Submitted_20220511

i '. r• 1 .I
Land-Disturbingrn i r i 'a ,1 r �� , t Permit Application`!I It 1 go
**The mailing and street address of the principal place of business for the person/entity financially responsible anal
the land owner(s) must be provided. A P.O. box is NOT acceptable as an address,
"If (he fins ncially responsible person/party is different from the current land owner, an agreement signed by both
parties must be provided allowing the financially responsible Harty person to conduct the land -disturbing activity on.
the property.
PROJECT NAME: Chatham Park Lots 738-743
DATE: 03-01-2022
ADDRESS OF PROJECT: Chatham Park - Near intx of Fire Tower Road & Tom Womble Road
LATITUDE/LONGITUDE OF PROPERTY AT SITE .ENTRANCE: 35.7289,-79.1599
PARCEL 4(S): 95092-95097
TOTAL DISTURBED ACRES or SQUARE FEET: 0.80 ac
PURPOSE OF ACTIVITY; To grade out lots In preparation for buildi
FEE AMOUNT SUBAUTTED: $500.00
structures.
+-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; Chatham Park Investors, LLC Phone: [phone]
Address: PO Box 3557
Cary, NC 27519
E-Mail: [e-mail]
Signature: _
"FINANCIALLY RESPONS1RT,F PARTY (annlicaMe. only Wdiffer'ent from nronei~<v nwner)
Name; Weekley Homes, LLC Phone: [phone]
Address: 1901 N. Harrison Avenue, Suite 200
Cary, NC 27513
E-Mail: [e-mail]
SibmatLrre:
NORTH CAROLINA AGENT (a licable only if owner or liti iiicially t-5ponsiblovatrtv does tiul reside in
Nnrth Carolina)
Name:
Address:
ENGINEEPUSURV -YOR
Corapany Name: The Nau rampany
Address: PO Box 810
RDlesville, NC 27571
Contact Person: Agnieszka Neu, PE
Phone: [phone]
E-Mail: anau@thenauco,com
Phone:
E-Mail:
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Pcrson: Stephen Hollingsworth
Company Name: ©avid Weekley Homes
Phone: [phone]
E-Mail: [e-mail]
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-� Soil Erosion and Sedimentation Control
C NA'1'l-)ArM C CIUN-TY
N " " 1 ff C. " "' I . Financial Responsibility/Ownership Form
PLEASE READ THE FOLLOWING INFORMATION:
l) This section must be signed in rho presence of a Notary
2) All Land -Disturbing permits are valid for up to (2) year; 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, AIso, upon
written nntice, a civil penalty (fine) can be instigated against the property owner andAor additional financially responsible party (if any)
for violations of the Chatham County Soil Erosion and Sedimeatatiolt 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 wi[lr 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 nle 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, attonicy-in-fact, or other person with authority to execute instruments for tho corporation and
accompanied by a complete Hs[ of all partners, managing members and registered agents of the company orcorporation.
OWNER OF PROPERTY:
Name and Title: �t_iw S''t --t-}r
Company (if applicable): Chatham Park Investors, LLC
Signature:
ADDITIONAL FINANCIALLY RESPONSIBLE PAR'I'Y (if any):
Name and Title: Ryan Wells, Division President
Company: Weaklay Hames, LLC
Sigoature:
NORTH CAROLINA AGENT (if any):
Nance and Title:
Company:
Signature:
1, `.l �` i/~1 , a Notary Public of County in the state
l-�IArrf ( t ✓l I do hereby certify that 1' personally
appeared before me this day and under Oath acknr►wlcdged reading the information above and acknowledged thatthe
above form was executed by him Or her. /} 4
wilr-es my hand and official seal, this the L day of , 20_1/'
�111111111IIIIIIIfff��i 1. Not y ublic T rt oJA R�I
My nrnissinn expiras (
r
1
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