NCC223103_FRO Submitted_20220902

Land -Disturbing
Permit Application
**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 to conduct the land -disturbing activity on the
property.
PROJECT NAME: CORCORAN RESIDENCE
DATE: JULY 13, 2022
ADDRESS OF PROJECT: 240 RIVERSTONE DRIVE PITTSBORO NC
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35.7312213,-79.1181407
PARCEL #(S): 91972
TOTAL DISTURBED ACRES or SQUARE FEET: 1
PURPOSE OF ACTIVITY: NEW SINGLE FAMILY HOME
FEE AMOUNT SUBMITTED: RIVER BASIN: CAPE FEAR
"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: SADLER CONSTRUCTION Phone: [phone]
Address: POB 17126 RALEIGH NC 27619
Name: SADLER CONSTRUCTION
Address:v�.
E-Mail: [e-mail]
Signature: rGcUC7A,�S-(CC .y-'
;able only if different from propertyownef
Phone: qC (0.7 031 __3>
E-Mail: ,,-b d v(.
Signature: r6CVCi ' _+) S-,1
NORTH CAROLINA AGENT (applicable only if owner or.financially responsible party does not reside in
North Carolusa)
Name:
Address:
ENGINEER/SURVEYOR
Company Name: SMITH & SMITH SURVEYORS
Address: POB 457 APEX, NC 27502
Contact Person: BEN SMITH
Phone:[phone]
E-Mail: [e-mail]
Phone:
E-Mail:
Signature:
EROSION CONTROL
Person to contact should erosion & sediment
control issues arise during land -disturbing activity:
Contact Person: LEWIS SADLER
Company Name: SADLER CONSTRUCTION
Phone: [phone]
E-Mail: [e-mail]
Page 2 of 3
ANTICIPATED START DATE: 08-2022 ANTICPATED END DATE: 08-2023