NCC232841_FRO Submitted_20230920

Land-Disturbing
CI IATI /�!AM C OUi N Y Permit Application
N 11 11 1 l A
**The mailing and street address of the principal place of business for the person/entity financially responsible and
the land owner(s)must be provided.A P.U.box is NOT acceptable as an address.
**If the financially responsible party indifferent from the current land owner,an agreement signed by both parties
must be provided allowing the financially responsible party to conduct the land-disturbing activity on the property.
This agreement is provided on page 3 of this application and must be completed in its entirety.
EI-Yousef New SFD DATE: 8/8/2023
PROJECT NAME: —
ADDRESS OF PROJECT: 1170 River Forest Rd,Pittsboro,NC 27312
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE:35.79863'49'/6514
PARCEL#(S): 1862
TOTAL DISTURBED ACRES or SQUARE FEEt t$WO SF
PURPOSE OF ACTIVITY: New SFD replacing existing home that is being moved off property
FEE AMOUNT SUBMITTED: TBD RIVER BASIN:CAPE FEAR
**LANDOWNER(S)OF RECORD (attach page to list additional owners)
Please provide a complete list of partners,managing members and registered agents if the responsible entity or
land owner is a group of individuals,corporate organization or entity.
Name: EI-Yousef Hassan ETUX Patrizia S Phone: [phone]
Address: 1170 River Forest Rd, Pittsboro,NC 27312 E-Mail: [e-mail]
Signature:
**FINANCIALLY RESPONSIBLE PARTY(applicableonnly if different from property owner)
t. �enne su �� a>,+ tie'r 1�.� d - C.
Phone: Y - Z �
�ft
Name: Jar ('�
Address: a t`"1 Q J c- n C i1 vac h c. _ E-Mail: c.� t..c:r-I 6 ti , Icicr: con^-\
Signature: y
NORTH CAROLINA AGENT(applicable only if either owner or financially responsible party does not
reside in North Carolina)
Name: Phone:
Address:
E-Mail:
Signature:
ENGINEER/SURVEYOR EROSION CONTROL
Company Name: Billings Land Surveys,PLLC, P-1485 Person to contact should erosion &sediment
Address: P.o.Box 824 Carrboro NC 27510 control issues arise during land-disturbing activity:
Contact Person: Joe Kennedy
Sam Billings _ _ Company Name: Heirloom Builders Inc.
Contact Person:Phone:[phone] Phone; 828.231-2081
[e-mail] E-Mail: [e-mail]
1rMail: ---_
Page 2 of 3
ANTICIPATED START DATE:
9/8/2023 ANTICPATED END DATE:9/8/2024

Soil Erosion and Sedimentation Control
CriAIl-JAM COUNTY
"""1 " ' ^^ ^' ^ 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)This form must be signed by the property owner if an individual.If owned bye 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.
3)This form must also be signed by the financially responsible party and NC agent(if applicable).Same provisions of#2 above apply.
4)1f 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 on this form is true and correct to the hest of my knowledge and belief and was provided by me while under oath.
6)All Land-Disturbing pennies 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 rs 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 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 written notice.
OWNER OF PROPERTY:
Name and Title: El-Yousef Hassan ETUX Patrizia S
Company(if applicable):
Signatur •
FINANCIALLY RESPONSIBLE PARTY(applicable only if different from property owner):
Name and Title: J 4se L, }��J1. cp r l n4L,1w
Company: r on M ?a,1-1 c''-rSVIN[" _ —Signature:
NORTH ARO INA AGENT(if any):
Name and Title:
Company:
Signature:
******************************************************************
1, L G.;Ir4s ,a Notary Public of Ot.us•• County in the state
of p.,ek C-4ft(,ni do hereby certify that_thig, F+-4E14f personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him or her. ri Witness my hand and official seal,this the ' day of 1441St.ir __,20 23.
1 C. /'...,4+4
Notary Public
Robert C. Gibbs
1�� �+
My commission expires t1/2ItaY NOTAR111Q�/ PUBLIC
Orange County, NC
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