NCC223902_FRO Submitted_20221122

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`Soil Erosion and Sedimentation Control
0 It T If C U. 41, z. r` * Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
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 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 party (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, 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.
5) Ibis form must also be signed by the financially responsible party and NC agent (if applicable). Same provisions of # 4 above apply.
OWNER OF PROPERTY:
Name and Title: T_ L (a T i i SOJ LA-K-
Company (if a plica }e): SADLER CONSTRUCTION, INC
Signature: u l' —
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title: G( �vZt(.1 LOK0 CR AA Gtv�' a.�-Y' -- - -- - - - -
Company: S E CON TRUFTION, INC
Signature: —L S V4-
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
a Notary Public of V461 Countyin the state
of A/or-f-Fl Gi tr t n CL_ _-do hereby certify that . _ 'personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thattbe
above form was executed by him or her.
Witness my hand and official seal, this the / 9 f1 day of U 1 , 20;Ld.
Notapy Public Z
N o
44 4 -
My commission expires
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