NCC222393_FRO Submitted_20220630

Land -Disturbing
Permit Application
Please complete both pages or this form and return to: For Office Use:
Physical Address Mailing Address
80 East St, 110 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-
91 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
a
one application with the, total amount of disturbance in acres for all parcel/lots. All clearing and
17T - VQ I%, UILLL I I I E, Ut3LUJ 11VU aL Or4,
Fee Requirements:
Permit, Fee: $25 Old isturbed acre
Plan Review Fee: $250/disturbed acre
Fees are rounded up to the next whole acre.
Example: I acre or less is $500, 1.01-2 acres is $1,000,and 2.01-3 is $1,500.
Plan Requirements:
Desian Plait: submit (1) copy of an erosion control plan curnploted & sealed by a professional land
survcyor, professional engineer, or registered landscape architect. This plan must meet the criteria of the
Chatham County Erosion Control Plan.Review Checklist and include ail 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 Cotm(y Watershed Protection wcbsite on the Residential Construction webpage. Indicate
lot drainage pattern(s) on sheet I. of the Residential General Plan.
D Residential Lot Permit. The following items are rcquircd to obtain this permit; completed
- application (if i-Lxluired, see note 4 on PEMITTING FLOW CHARI), site plan, and fee,
Fee, Requirements: Plan Requirements:
$ 100 flat fee Site Plan showing property boundaries. The site plan required by the
Fnvironmental Health or Central Permitting Departments is sufficient.
-
ALL CHECKS MADY, NYABLE TO CffATHAM COUNTY
Page 1 of 3

Y�aiid-Distiirbing
.i t'i'!t `>� ° Permit Application
,-The rnaiiing and street a+ldress of the prineipal place of business for (lie perioWeatity Financially responsible and
ilre land nwritr(S) rnir,t lie. provi4ed..A P-0, box is NOT acceptable as an Adress.
*If the,: finaneiaiCr• re.pon0l*l personlpurty is different from the current land unvnex, an agreenteni signed by Loth
pnrties ttlust lie pr:lvidr..l allowing tilt financially responsible party person to Conduct they hanet-disturbing activily on
the pralierty.
PROJECT NAME,- Chatham Park Lots 1003-1154
DATE: 03-16-2022
ADDRESS OF PROJECT: Chatham Park - Near Grant Dr. & Sutties Rd
LATITUDE[ ONG1TUDE OF PROPERTY AT SITE ENTRANCE: 36.7506-79,1601
PARC'.EL #(S): AKPAR:7101
TOTAL DISTURBED ACRES or SQUARE FEET- 24.52 ac
PURPOSE OF ACTIVITY: To grade cui lots in preparation for hulldlnrg structures.
FEE AMULINT SUBMITTED: $12.500.00
*`LANDOWNEIt(S) OF IZECORD (attach paRc to list additional owners)
Please provide, a complete list of partners, managing,nernbers and registered agents if the responsible catity 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: ..._,
"TINANCIALLY RESPONSIBLE PARTY (applicable only ifdiflerent from prouertvowncr)
Name: Weekley Homes, LLG phone: [phone]
Address: 1901 N. Harrison Avenue, Suite 200 E_Vtail: SHollingsworth@dwhames.c m
Cary, NC 27513 Signature:
NORTH CAROLINA AGENT (ahpIic-Lible only ihowncr or Iitianc_itt_Ily responsible party does not reside nt
North Carolina
Name:
Address:
ENGNF :R/SURVEYOR
Company Name; The Nau Company
Addregs: Po Rnx 810
R,olesville, NC 27571
Contact person: Agnieszka Nau, PE
Phone: [phone]
E-Mail: [e-mail]
Phone:
E-Mail:
Signature;
EROSION CONTROL
Persun to contact should erosion & sediment
control issues arise during land-disturbingaetivity:
Contact Parson: Stephen Holllogsworih
Corxrpany ~Tame: David Weekley Homes
Phone: [phone]
E-Mail: SHalGngsworlh@dwhomes,00m
Page 2of3

Soil Erosion and Sedimentation Control
C HAXUTAM C_(h1�N7'Y
Financial Responsibili(y/Ownership Form
PLFASE R1;A D ' I'H F. For ,LO VV ING INFORMATION:
1) This section mum be signed in the presence of a Ntrtaty
2) All Land -Disturbing permits are valid for up to (2) years from the date of issuance. If uircrmistances warrant, the patmit may be
extended for (2) years per the conditions of the Chatham County Sail i~rosinr and Sedimentation Control ()rdinance. Upon written
notice, the'Land-Disturbing permit may be revoked for failure to u/mply 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 properly owner and/or additiurial financially responsible party (if any)
for violations of the Chatham County Soil Erosion and Sedimentation Conlrol Ordinance. This penalty is up to $5000.00 per violation
per tlav and is assessed daily for every day the property is iu violation. interfering with or hampering an inspection can result in a civil
penally without written noticr.
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 awner if an individual. If owned by a company or cotporntion, 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:
Nameand1itle:2o:3lxl 1.-�oSas - DcGisrni�ADN 4czwf;
Company (if appl icabLL Chatham Park Investors, LLC
Signa lre:
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title. Ryan Wells, Division President
Company:
Signature:
Homes, LLC
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
11 1, ,, , a Notary Public oCounty in the state
of r do hereby uerlify that I V1 G��Qi personally
appeared before the this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him or her. 11VIM
Witnofficial
es. ry hand and ocial seal, this the day of '�✓(. 2011-
eA
�' \,1rulnnr„
Nol' r i'uhlic / ,r �jI !/��f�//1 ,gyp\\\�O AR 1 A
Y pV6U464 YM commission ex ices
y,
- / 1
- 1 =
,c
Page 3 of 3 couN
���,,/1j1JA111111i1\\\\