NCC222625_FRO Submitted_20220725

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Internationally Recognized for Program Excellum
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
140 Memorial Park Court
Southern Pines, North Carolina 28387
Telephone: [phone] — Fax: [phone]
No person may initiate any land -disturbing activity greater than 30,000 sq. ft. (including lots or tracts of land that are
a part of a Common Plan of Development that the total disturbance will exceed 30,000 sq. ft.) as covered by the
Town's Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been
completed and approved by the Town of Southern Pines. (Please type or print and, if the question is not applicable
or information unavailable, place NIA in the blank.)
Part A.
1. Project Name: The Luxe at Morganton Park
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address S. Carlisle St.
3. Latitude: 35.178 Longitude:-79-417 PIN: 857200502304
4. Percent Impervious: 4.04 acres
5. Approximate date that land -disturbing activity will commence: December 2021
6. Purpose of development (residential, commercial, industrial, institutional, etc.): RE
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
8. Amount of fee enclosed: $
The application fee is $300.00 for the first acre plus $150.00 for each additional acre, or part thereof.
The revised plan review fee is $50 for each submittal after the 2nd review.
Any substantial revision to a previously approved, active plan is $50 per acre, or part thereof.
No Fee for Minor Construction Activities less than 30,000 sa, ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John NeRld E-mail Address Jneild25 �yahoo.com
Telephone [phone] Cell # 910-263-9611 Fax # NIA
10. Landowner(s) of Record (attach accompanied page to list additional owners): Please See Attached Page
Robert W & Julie M Van CampTrustees 910-295-2525 NIA
Name Telephone Fax #
P.O. Box 1389 2 Regional Circle
Current Mailing Address Current Street Address
Pinehurst, NC 28370 Pinehurst, NC 28374
City State Zip City State Zip
11. Deed Book No. 1589 Page No. 80 (Provide a copy of the most current deed).

LUXE AT MORGANTON PARK
ADDTIONAL OWNERSHIP INFORMATION ATTACHMENT
FINANCIAL RESPOSIBILITY/OWNERSHIP FORM
Morganton Park, LLC
Name
639 Executive Place, Suite 400
Current Mailing Address
Fayetteville, NC 28305
City State ZIP
910-481-0503 N/A
Phone FAX
639 Executive Place Suite 400
Current Street Address
Fayetteville, NC 28305
City State ZIP
Deed Book 4192 Page 583 Deed Copy is attached

Part B.
1. Person(s) or firm(s) who is Financially responsible for the land -disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
Morganton Park II, LLC casey(o)cavinessandcates.com
Name E-mail Address
639 Executive Place Suite 400 639 Executive Place, Suite 400
Current Mailing Address Current Street Address
Fayetteville, NC 28305 Fayetteville, NC 28305
City State Zip City State Zip
Telephone [phone] Fax # NIA
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
NIA
Name of Registered NC Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax #
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of NC Registered Agent E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City
Fax #
State
Zip

The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
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Typ or rint name Title or Aut rit
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Sig tune Date
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`j�1G,�np a Notary Public of the County of
State of North Carolina, hereby certify that a
appeared personally before me this day and being duly sworn acknowlekided that the above form
was executed by him.
Witness my hand and notarial seal, this d 1 day of _LLQ\j ennOOu-r, 20-9L—
�.rQ,• �o�ARY
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FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑
4
M Cu
m' h
No ❑
Notary 1` L.Lb\ c.
My commission expires S i 1 �Q -a 5
REVISED: January S, 2020