NCC222867_FRO Submitted_20220810

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 j
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 oe 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: I acre or less is $500, 1.01-2 acres is S1,000, and 2.01-3 is $1,500.
Plan Requirements:
Desien 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. "Phis 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 webpate. Indicate
lot drainage paitern(s) on sheet I of the Residential General Plan.
21 Residential Lot Permit. The following items are required to obtain this permit: completed
application. site plan, and fee. PAGE 3 "FINANCIAL RESPONSIBILITY/OWNFRcutn FnVh,4`
not re uire .
Fee R uirements: Plan Requirements:
$100 flat tee 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 Iof3

L/
sand -Disturbing
Permit Application
Homefront Builders Inc. dba Dunning Custom Homes
"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 an
the property.
PROJECT NAME: Lot 50LR - Raymer Project DATE. 6/3012022
ADDRESS OF PROJECT: 397 Blufftonwood Drive, Pittsboro NC 27312
LATITU'DE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35807584795328815-792105835887275
PARCEL #(S): 94679
TOTAL DISTURBED ACRES or SQUARE FEET: 24350
PURPOSE OF ACTIVITY- SFD
FEE AMOUNT SUBMITTED:
**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: Michael and Deborah Raymer phone: [phone]
Address: 1185 51, Cloud Loop. Apex, NC 27523 E-Mail: [e-mail]
Signature:�rn t > ~a _ _• ?.€a
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from pronf-gyownet )
Name: _,John Dunning Homefront Builders Inc. dba phone: [phone]
Address -Punning Custom Homes E-Mail: [e-mail]
1297 Chatham Church Road Moncure, NC 27559;
Signature:
NORTH CAROLFNA AGENT (applicable only if owner or financially responsible patty does not reside in
North Camlma)
Name. phone:
Address:
ENGINEER/SURVEYOR
Company Name: Lester stanciii and Associates PLS, PA
Address: PO Box 730, 98E, Depot St. Angier NC 27501
Contact Person: Lester Stancil
Phone:919-M9-2133
E-Mail: [e-mail] --
E-Mail:
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Pelson: Joe Kelly
Company Name: Kelly's North Carolina
Phone: [phone]
E-Mail: kellync.of#ice@gmaiLcom
Page 2 of 3

Soil Erosion and Sedimentation Control
Financial Responsibility/Ownership Form
NOT REQt'JRED TO BE C'OMPLFTED FOR RESIDENTIAL LOT PER 10 S.
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 properly 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 ofthe 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: Michael Raymer and Deborah Raymer
Company (if applicable):
Signature:
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY (if any):
Name and Title: John Dunning
Company.
Signature:
NORTH BAR
Name and Title:
Company:
Signature:
Inc. dba Dunning Custom Homes
AGENT (if any):
1, 5�tn it (4c01`r. r:aFcc.
. a NotaryPublic of
r County in the state
Of isc .t+ °; .r am q do hcrcby certifi, that :'V 1CHAC(._ i-.� i.aa� w� 3�zs : N. �r�(a+c 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.
5 i..
Witness my hand and official seal, this the 1 __day of '/202 Z
totaryyublic SHAUN PEREIRA
= J / NOTARY PUBLIC
My commission expires_ 'NAKE COUNTY, l�l
My Commission ExyEre1 Va023
Page 3 of 3

G.S. § 1OB41 NOTARIAL CERTIFICATE FOR
ACKNOWLEDGMENT
Ckp�tftCounty, North Carolina
I certify that the following person(s) personally appeared before me this day, each
acknowledging to me that he or she signed the foregoing document:
kJme(s) ofprincipal(s)
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Date:
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Official Signat f Notary
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My commission expires: