NCC240091_FRO Submitted_20240112

Applications may be submitted online:
rt https://chathamcountync.viewpointcloud.com/categories/1082
Land-Disturbing
ChIATI IA All COUNTY Permit Application
NI (3 Il r N l' A It ft 1. I N A
Please include all required signatures. For Office Use:
Physical Address Mailing Address
80 East St. PO Box 548
Pittsboro,NC 27312 Pittsboro,NC 27312
Phone: [phone]
Please see PERMITTING FLOW CHART to determine which permit, plan, and fee requirements
apply to your project and then check one of the boxes below:
Land-Disturbing Permit. The following items are required to obtain this permit: completed
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 are rounded up to the next whole acre.
Example: 1 acre or less is$500, 1.01-2 acres is$1,000, and 2.01-3 is$1,500.
Plan Requirements:
Design Plan: submit(1) 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
Chatham County Erosion Control Plan Review Checklist and include all applicable construction details.
These can be found on the Chatham County Watershed Protection website, on the Erosion Control
webpage. This plan must satisfy all local, state, and federal minimum plan requirements.
General Plan: submit(1) copy of site plan showing proposed disturbance limits along with the Chatham
County Residential General Plan. Site plan is not required to be completed by a design professional. The
Residential General Plan can be found on the Chatham County Watershed Protection website,
Residential Land-Disturbing Permit webpage. Complete table on sheet 1 of Residential General Plan.
0 Residential Lot Permit. The following items are required to obtain this permit: completed
application, site plan, and fee. Page 3 "Financial Responsibility/Ownership Form"not required.
Fee Requirements: Plan Requirements:
$100 flat fee Site Plan showing property boundaries and proposed disturbance limits. The site
plan required by the Environmental Health Department can be used as a base.
ALL CHECKS MADE PAYABLE TO CHATHAM COUNTY
Page 1 of 3

Land-Disturbing
C'IIATIIAIN C'OLIN"I1"
It I II t A ftt i Permit Application
**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.O. box is NOT acceptable as an address.
**If the financially responsible party is different 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.
PROJECT NAME: Briar Chapel SD East Fitness Facility DATE: 1/13/2023
ADDRESS OF PROJECT: Market Chapel Road,Fearington,NC 27312
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35°48'36.6"N/79°5'24.2"W
PARCEL#(S): AKPAR No.93102 and 93204
TOTAL DISTURBED ACRES or SQUARE FEET: 3.55 acres
PURPOSE OF ACTIVITY: Construction of a fitness facility and associated parking area
FEE AMOUNT SUBMITTED: $2000.00 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: NNP Briar Chapel LLC Phone: [phone]
Address: 13777 Ballantyne Corp Place,Suite 250 E-Mall: [e-mail]
Charlotte,NC 28277 Signature:
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner)
Name: Wilson Blount Development,Inc. Phone: [phone]
Address: 2626 Glenwood Ave,Suite 350 E-Mail: wcozart@wils nblount.corn
Raleigh,NC 27608 Signature:
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: McKim a creed.Inc. Person to contact should erosion &sediment
Address: 1730 Varsity Drive,Suite 500 control issues arise during land-disturbing activity:
Raleigh,NC 27606 Contact Person: Whitt Cozad
Contact Person: K.Luke Turner Company Name: Wilson Blount Development, Inc.
Phone:[phone] Phone: [phone]
E-Mail: [e-mail] E-Mail: [e-mail]
Page 2 of 3
ANTICIPATED START DATE: March, 2023 ANTICPATED END DATE: September, 2023

Soil Erosion and Sedimentation Control
CH NTH Al%4 COUNTY
N S1 R 1 11 C A 1%Q I. . N 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)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#2 above apply.
4)If the 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 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 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)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.
OWNER OF PROPERTY:
Name and Title: Tanya Matzen,Vice President of Operations
Company(if applicable): Brookfield Properties
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title: Whitt Cozad,Managing Director of Development
Company: Wilson Blount Development
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
******************************************************************
I, ?PP ti(t1/4/// ,a Notary Public of (4/iKE County in the state
of NUR III C/f8O4/4/4 do hereby certify that W/f/iT CO2/fR T 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.
Witness my hand and official seal,this the day of ,7411/O t Ry ,20 2.3.
NotaryPublic - David Williams
NOTARY PUBLIC
My commission expires SEPrEM13ERG,20%6 ( rAth ounna
My Commission Expires September 6,2026
Page 3 of 3

Permitting Flow Chart
CPOD = Common Plan of Development2
Design Plans are required to be
completed by a PE,PLS,or RLA Non-Residential Construction
and must meet the requirements of: Residential Construction
Chatham County Checklist for Plan Start Here
Submittal. Start Here3/4
Yes Willtfieproject
..44/41111*, disturb
>20,000 sq.ft.?
No Yes No
Will the project' .
disturb410110
Project in a
>25,000 sq.ft.? CPOD?
No
No Yes Yes Yes
No NO •
PERMIT
V
REQUIRED
Land and Land Land
sidential Re CDisturbing Disturbing Disturbing Disturbing
Lot Permit Permit Permit Permit Permit
Required Required Required Required
V' Y W
1)Fees:
1)Fees: 1)Fees: Plan Review:$100/lot 1)Fees: 1)Fees:
$100 flat fee $500/disturbed acre Permit:$250/disturbed acre $500/disturbed acre $500/disturbed acre
2)Plan Requirements:Site 2)Plan Requirements: 2)Plan Requirements: 2)Plan Requirements: 2)Plan Requirements:
plan w/property boundary& Design Plan Design Plan or General Plan Design Plan Design Plan
o
proposed disturbance limits
1.All projects requiring a Land Disturbing Permit from Chatham County must complete the same application.It is a three page application called Land Disturbing
Permit Application.Signature on Page 3 should be completed at a notary.
2.Common plan of development examples:subdivisions,commercial property,campuses.Others can include any announcement,documentation,or physical
demarcation indicating construction activities are planned to occur on a specific plot of land regardless of ownership of the parcels.
3.A Residential Lot Permit is not necessary for new additions(e.g.porches,patios,bedrooms,garages).
4. Driveway,septic&septic line,well,utilities,yard,and any area of natural or existing groundcover planned to be disturbed must be included when calculating
disturbed acreage for residential lots.

Land-Disturbing
CI I A T I IA NI (2 )L.I N TTh'
I. IC r II L A I• III I A Permit Application
**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.O. box is NOT acceptable as an address.
**If the financially responsible party is different 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.
PROJECT NAME: Briar Chapel SD East Fitness Facility DATE: 1/13/2023
ADDRESS OF PROJECT: Market Chapel Road,Fearington,NC 27312
LATITUDE/LONGITUDE OF PROPERTY AT SITE ENTRANCE: 35°48'36.6"N/79°5'24.2"W
PARCEL#(S): AKPAR No.93102 and 93204
TOTAL DISTURBED ACRES or SQUARE FEET: 3.55 acres
PURPOSE OF ACTIVITY: Construction of a fitness facility and associated parking area
FEE AMOUNT SUBMITTED: $2000.00 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: NNP Briar Chapel LLC Phone: [phone]
Address: 13777 Ballantyne Corp Place,Suite 250 E-Mall: tanya.matzen@brookfietdpropertiesd veiopme m
Charlotte,NC 28277
Signature:
**FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property o ne
Name: Wilson Blount Development,Inc. Phone: [phone]
Address: 2626 Glenwood Ave,Suite 350 E-Mail: [e-mail]
Raleigh, NC 27608 Signature:
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: McKim&Creed.Inc. Person to contact should erosion &sediment
Address: 1730 Varsity Drive,Suite 500 control issues arise during land-disturbing activity:
Raleigh,NC 27606 Contact Person: Whitt Cozart
Contact Person: K.Luke Turner Company Name: Wilson Blount Development,Inc.
Phone:[phone] Phone: [phone]
E-Mail: [e-mail] E-Mail: [e-mail]
Page 2 of 3
ANTICIPATED START DATE: March, 2023 ANTICPATED END DATE: September, 2023

Soil Erosion and Sedimentation Control
CHATHAM Cc LINY T
N(1 K T}. C A R o .. 1 N 4 Financial Responsibility/Ownership Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTIAL LOT PERMITS.
PLEASE READ THE FOLLOWING INFORMATION:
I)This section must he signed in the presence of a Notary.
2)This form must be signed by the property owner ifan individual. If owned by a company or corporation.this form must be signed by an officer,
director.partner.attorney-in-tact.or other person with authority to execute instruments for the corporation and accompanied by a complete list of all
parolers,managing members and registered agents of the company or corporation.
3)This tbrm must also be signed by the financially responsible party and NC agent(if applicable).Same provisions of#2 above apply.
4) If the landowner and financially responsible party are different,the completion and signing of this page shall serve as documentation
acknowledaing 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 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) 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(tine)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.
OWNER OF PROPERTY:
Name and Title: Tanya Matzen,Vice President of Operations
Company (if applicabl N t-(ktc -e U"C---
Signature:
FINANCIALLY RESPONSIBLE PARTY (a plicable only if different from property owner):
Name and Title: Whitt Cozart,Managing Director of Development
Company: Wilson Blount Development
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
******************************************** =*********=k***********
I. A �... r , a Notary Public of Q Y0.V1ne County in the state
of Npr Ciajro l t d% do hereby certify that jaJ A A wkeet 'ZLv-1 personally
appeared before me this day and under oath acknowledged reading the in' Irmation above and acknowledged thatthe
above form was executed by him or her.
Witness my hand and official seal,this the 17 day of Jan n.... .20 25
041
Notary P is
My coma .sion expires
to �Z�z 3 5 (s i, 0� R Y
,
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Page 3of3 . ' .
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