NCC232172_FRO Submitted_20230721

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('lease include all required signatures. — l
Physical Address Mailing Address
S0 Fast SrPO 13ox 545
11IItshorO. NC 27312 Pitsboro, NC 27312
Phone: [phone] _
Please see IT KNITTING FLOW CHARTto determine which permit, I
apply to your project and then check one of the boxes below: plan,and fee requirements I
i
-1:3 -Land=l?isturbing Permit. The following items are required to obtain this permit: completed 1
application, plans. deed. and fees. All clearing and disturbance must be included when calculating disturbed area.
Fee Requirements: —_ -- -- - —
See attached PERMITTING FLOW CHART
For fees that arc rounded up to the next whole acre. ---Example: 1 acre or less is$500, I.01-2 acres is$1.000,and 2.01-3 is$1,500.
Plan Requirements:
1)es12n Plan: submit (I)copy of an erosion control plan completed& sealed by a professional land
surveyor. professional engineer.or registered landscape architect. This plan must meet the criteria of the
(-hathatu County Erosion Control Plan Review Checklist and include all applicable construction details.
• Thee can be found on the Chatham County Watershed Protection website,on the Erosion Control
kt chpa e. This plan must satisfy all local, state,and federal minimumplan requirements.
General Plan: submit (I)copy of site plan showing proposed disturbance limits along with the Chatham
t minty Residential General Plan. Site plan is not required to be completed by a design professional. The i
Residential General Plan can be found on the Chatham County Watershed Protection website,
Residential Land-Disturbing Permit webpagc. Complete table on sleet I of Residential General Plan.
2 Itetiidcntial Lot Permit. The following items are required to obtain this permit: completed
I(,ph( .n,in. site plan. and lee. Page 3 "Financial Responsibility/Ownership Form”not required.
I Le Requirements: ; Plan Requirements: — —
100 flat fee 1 Site Plan showing property boundaries and proposed disturbance limits. The site
plan required by the Environmental Health Department can he used as a base.
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Permit ‘I)Itlication
• The mailing and street address of the principal place of business for the person/entilt linanciall responsible and
Oh' land ow ncr(s) mull he provided. A P.O.box is NOT acceptable as an address.
It the financially responsible part. is different from the current land owner.an agreement signed by both parties
mrr`t he provided allowing the financially responsible party to conduct the land-disturbing activity on the property,
II
this agreement is prop ided on page 3 of this application and must he completed in its entirety.
I
' I'RO.II•:('T \ANIL: Kearns Residence j
DATE:
ADDRESS OF PRO.IECT: 0 Billets Run,Moncure Nc
I.NTl l'lE/LONGITUDE. OF PROPERTY AT SITE ENTRANCE: 35.627520/-79.064690
I' \WTI.#(S): 81652 i
I O I \L DISTURBED ACRES or SQUARE FEET: 3$,275
PURPOSE OF ACTIVITY: New Construction SF^
FEE AMOUNT SUBNIIT7•ED: RIVER BASIN:CAPE FEAR
"LANDOWNER(S)OF RECORD(attach page to list additional owners) I
Please provide a complete list of partners. managing members and registered agents lithe responsible entity or
land owner is a group of individuals. corporate organization or entity.
\„me: Justin and Jaisa Kearns Phone: [phone]
Address: 179 Billets Run, Moncure, NC 27559 E-mail: [e-mail]
e•___ __4 .
- Signature
**FINANCIALLY RESPONSIBLE PARTY(applicable only if different from
Name: property owne Il t
— _ Phone:
Address: E-Mail:
Signature:
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Phone:
Addt cs.: -Mail:
— _ Signature: -
II:NGIN'I.I It SI 'RVI.YOR EROSION CONTROLI
( rmrp it ",'I" ILJIG W l_-_to J2olkYcrsn11 to contact should erosion & sediment
1 0 A r, . (ql� wQ'nS
lY �` control issues arise during land-disi nrlrinrs its:
('onlacl Person:T)i ltyl; r.....tr �,1
-vz
• I, V � ,wGO ('ungr,m) Name: Scrt�ll vseY neon
I • VeGYI e 2,is - NC .cer-n I \i.,,l 0 nc\ e. e 5cniAnykoftey h9r02.5 _Can.
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.t t,�t ILA ( t)��1V� , Soil Erosion and Sedimentation ('nnlrt►I
1 11 .1 .1 11 .. 1� Financial lied)nnsil►ililV�/Ot,�"ncrshil) Form
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;Vor/?/iO-IRLl) n)BE('UJII'/.E77: )FOR h'/iSf/ /A'//.-1L LOT PL11;t//7:5'.
I'I-FASF: READ"fill: FOLLOWING INFORMATION:
I) 1 his section must he signed In the presence of Notary.
') .1111s form must be signed by Mc property°sync' it an nuti%Ideal, If owned by a company or corporation.Ibis lonn must be signed by an°trice.
dncc Cot.patina.attorney-nt•haci or othct person with authorit to execute instruments for the corporation and accompanied by a complete list°I all
partners- tin Igntg members and registered agents athe cninp.uts in coronation.
I flips form must also be signed Its the financially responsible'salty and Nl•agent(if applicable).Same provisions of g 2 ribose apply I
al If the I:utdoss ncr and financially responsible party ate different,the cinnpletton and signing of this page shall serve as documentation
acknoss Inigutg the lan(1ownet consents to and authorizes the financially responsible party to undertake the proposed land-disturbing activity on the
Iunloss tel tiacI)s)of land identified on this application.
51 The information provided on this form is true and correct to the best of my knowledge and belief and was provided by inc while under oath
ill All I and-Disturbing permits are valid for up Io(2)ye.us lionm the date of issuance. If circumstances warrant,the permit may he extended for
(`) years per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance. Upon written notice, the Land-Disturbing
mom may be revoked for tirilurc to comply ss oh the Ordinance. If the permit is revoked, all other permits and approvals are ssithhcld until
the pioperty is once again in compliance ss ilk Chatham (bunts regulations. Also,upon ssrillen notice.a civil penalty. dine)can be instigated
against the property o's net andior additional financially responsible party(it any)for violations of the Chatham County Soil tirosion and
Sedimentation Control Otdt Lance This penally is up to S500).O0 per s iolatoil pet day and is assessed daily lot es cry day the properly is in violation
Interfering ss uh or hampering an inspection can result in a civil penalty ss ithout written notice,
OWNER OF PROPERTY:
\.one and Title: Justin&Jaisa
( timpani(if ap ie): Owner
Si_nattu'c: I-�, _
FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner):
Name and Title:
Company:Signature:
NORTH
NORTH CAROLINA AGENT(if any):
Name and Title:
('nmpany. _ — —
`signature: ..—
x= *•r'.*****:,:* r.
;;***** x**>h**%,=****** .:********* ,
I. a Notary Public of
of NQ �)ro (Clo7 — do hereby certify that — —('ourtly in the state
ii1 a i94 ,-nS
appealed before Ole this day and under oath acknowledged reading the information above and acknowledged that'the
y
ahi,s c form was executed by him or her.
11 1lncss my hand and official seal,this the_ day of_—I!-1 _,..2..02
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