NCC233071_FRO Submitted_20231013

CLaATNAJM C urn r Soil Erosion and Sedimentation( unirol
'"" ' '"" Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERA TS
PLEASE READ THE FOLLOWING INFORMATION:
I 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 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.
3)This form must also be signed by the financially responsible party and NC agent(if applicable)Same provisions of a 2 above apply
4)lithe landowner and financially responsible party are 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 activ itc on the
lardowner's tract(s)of land identified on this application.
5)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
6)All Land-Disturbing permits arc 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 Sod 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.
Interfenng with or hampering an inspection can result in a civil penalty without written notice.
OWNER OF PROPERTY:
Name and Title: Suzie Gole-Owner/Financially Responsible Party
Company(if applica e): •
Signature:
FINANCIALLY RE NSIBLE ARTY(applicable only if different from property owner):
Name and Title: Na
Company:
Signature:
NORTH CAROLINA AGENT(if any):
Name and Title: Na
Company:
Signature:
1, /ve: i,f)si/h6fd a Notary Public of /,(4i/l/QmsP4 County in the state
of 7EJq n do hereby certify that iZ ZgyM em.he personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged that the
above form was executed by him ott"tier! � ����
Witness my hand and official seal,this the / day of V 7a y 20
tORIANN BURCHFIELD
Notary bite NOTARY PUBLIC
My commission expires b/%°76 O6 14/0 rYscrcarjums25
NOTARY ID 12921549A1
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