NCC224131_FRO Submitted_20221220

Soil Erosion and Sedimentation Control
C'1-1 A II I A lei C" i N-1-V
"" •' " " W. A Ot ' 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 circumstance~ 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 Ilse property is once again in compliance with Chatham County regulations. Also, upon
writtell notice, a civil penalty (fine) can be instigated against the property owner and/or additional financially responsible party f 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 fur every day the property is in violation. Interfering with or hampering an inspection earl result in a civil
Penalty without written notice.
3) The information provided oil this form is true and correct to the best of illy knowledge and bclicf'and was provided by me while
under ouch.
I) This form must be signed by the property owner if all individual. if owned by a company or corporation, this form nlus[ be signed
by an officer, director, partner, attorney -in - fact, or other person with authority lu execute instruments f0l' the corporation and
accompanied by a complete list ol'all partners, managing members and registered agents of the company or corporation.
OWNER OF PROPERTY:
Name and Title: Harry Krohn VP
Company (ifa pli ble): Windjam 23 LLC
Signature; �µnuuna,p�
ADDITIONAL Fi ' NCiALLY RE5P0 iBLE PA Y (if an : J q� .' �'a 6 �
Name and Title: �r 0�%/V [ y)1�•�"
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Company: S CA7 Air,' II L • '
Signature: a41 r
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NORTH CAROLINA AGENT (if any): z� d NQS� ;�•�
Name and Title:
Company:
Signature:
I' a Notary Public ofVIA A
County in the state
t" ��dohercby certify that ` personally
appeared before me this day and tinder oath acknowledged reading the information above and acknowledged that the
above fern, was executed by him or tier.
Witness my hand and official seal, this the •`���r� day of_ YY C , 201�
C NaaaaH•••Nrrrf•r
.t'L �►�71.tSON P �.�
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Notary Public
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My commission expires _ (SEAL) s
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