NCC232077_FRO Submitted_20230712

• Soil Erosion and Sedimentation Control
CH Al'I-IANI C'c)uraTY
s. it . t A 1: �, I- r A 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.
OWNER OF PROPERTY:
By: Liberty Real Properties II, LLC, Member and Manager, By: Ronald B. McNeill, Manager
Name and Title:
Company(if applicable): Lib rty Healthcare Properties of Chatham County. LLC
Signature: / /lam-�f�
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY(if any):
Name and Title:
Company:
Signature:
NORTH CAROLINA AGENT(if any):
Name and Title:
Company:
Signature:
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, �'y � COU � sofW ll rt cam � do hereby certify thatak/ personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
Bove form was executed by him or her. II r
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