NCC230257_FRO Submitted_20230130

Soil Erosion and Sedimentation Control
Financial Responsibility/Ownership Form
YVOT REQUIRED TO BE COMPLETED FOR RESIDENTI,4L LOT PERMITS.
PLEASE READ THE; FOLLOWING INFORMATION:
I ) This section must he signed in the presence of a Notary,
'_) This litre must he signed by the property owner Wan individual. If owned by a company or corporation. Illk form must be signed by an officer,
director. partner, atiorrky-in-lace. or other person with authority to execute instruments lbr the corporalion and accompanied by a complete list ol'all
partners, managing members and registered agents o['the company or corporation.
3) This torn must also he signed by the financially responsible party and NC agent (if applicable►. Same provisions ol'4 2 above apply.
4) If the landowner and financially responsible party arc different, the completion and signing of this page shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land -disturbing activity on the
landowner's tract(s) of land identified on this application.
5) The information provided oft this form is true and correct to the best of my knowledge and belief and was provided by me while under oath.
6) 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) )rears 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 (tine) can be instigated
against the property owner and/or additional financially responsible party (if an)') For violations of the Chatham County Soil Erusion and
Sedimentation Control Ordinance. This penalty is up to 55000.00 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 writwn notice.
OWNER OF J
Name and Title:
Company (ifapl
Signature: —
FINANCIALLY
Natne and Ti
Company: _
Signature:
� \ l lk LW- t;"v t L-
ESPONSZ,BLE PARTY (ap 1Ecable only if different from property owner):
NORTH CAROLI]\A AGENT (if any):
Name and Title:
Company:
Signature:
1,A4 a Notary Public: of -A _County in the start~
of do hereby certify that ot..✓talu Ackr'Ln,- personally
appeared before me this day and tinder oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her.
Witness m nd and official seal. this the +ar!- day of )ii 20:
�\``\\``% p R[YIP 4111•'���f.
No tt lie +.`
My commission expires ELRN_;
1 Davrckon County
My Commission Expire®
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