NCC223793_FRO Submitted_20221110

Soil Erosion and Sedimentation Control
CHArF1A_M CC)t NTY
rq o Ft 1-.3 C A R O L l M A Financial Responsibility/Ownership Form
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 (1) year per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Uponwritten
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. Also, upon
written notice, a civil penalty (fine) can be instigated against the property owner and/or additional financially responsible parry (if any)
for violations of the 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, attomey-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 orcorporation.
OWNER OF PROPERTY:
Name and Title: L V'l S
Company (if applicable):
Signature:
ADDITIONAL
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
ONSIBLE PARTY (if any):
I, t" Safi r+i4 'Snccs , a Notary Public of---Frat11CA. n County in the state
of do hereby certify that Sj 0.av_trlce` ersonally
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.
Witness my hand and official sea], this the 14A day of_IL �,r' 20'3-1.
4
ARIETTA ,ZONES
Notary Public Notary Public
My commission expires o� r7k
�mm�' �"a
August 25, 202
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