NCC233174_FRO Submitted_20231025

I�� FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of SEDIMENTATION POLLUTION CONTROL ACT
outhern ines Public Works Department
140 Memorial Park Court
� . n;,, Wr The Soutl Irmo i Southern Pines, North Carolina 28387
Internationally Recognized For ProgrammEx. Resorr Telephone: [phone]—Fax: [phone]
Excellency
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 N/A in the blank.)
Part A.
1. Project Name: II Monteith Ploice
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address II Monteith Place PinehuYs+, NC 239-'1
3. Latitude: 35 .22°1220 Longitude: -1-61•4I22.10 PIN: '059-30ibS9 .509
4. Percent Impervious:
5. Approximate date that land-disturbing activity will commence: 10 15 120 Z 3
6. Purpose of development(residential, commercial, industrial, institutional, etc.): resi d e n tl o
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
8. Amount of fee enclosed: $ N IA'
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 sq. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tyler Coo K E-mail Address1ijIer Iatitudebullders.Com
TelephoneCCI 10) 31 6.'1 Cell# Fax#
10. Landowner(s)of Record (attach accompanied page to list additional owners):
Scott & Meghan Harry
Name Telephone Fax#
046 Old Club House Lane Same,
Current Mailing Address Current Street Address
Southern p i neS NC 2E3a
City State Zip City State Zip
11. Deed Book No. 5°l eo Page No. 443 (Provide a copy of the most current deed).

rt B.
Person(s)or firm(s)who is financially responsible for the land-disturbing activity
1.
(Provide a comprehensive list of all responsible parties on an attached sheet):
Latitude ,Builders- -t Ier@ Ia1-1J de ,buiIders .eorri
Name E-mail Address
PO 13oX 1301 132 Nw 6r0a0 St, Sulk �
Current Mailing Address Current Street Address
Southern pines NC. 263ee couthan Pines Nc 2�3�fi
City StateA Zip City State Zip
Telephone (II d) (oCl O -3-1 !q Fax#
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:
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 Current Street Address
City State Zip City State Zip
Telephone Fax#

le above information is true and correct to the best of my knowledge and belief and was provided
oy 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.
—10ce (vtic it\et-Ao.r
Type or print name Title or Authority
9f9k3
Signature Date
I, K Qi S36A S-c(2-4i1b..-SE40Flia Notary Public of the County of -(r)CO'(ZS
State of North Carolina, hereby certify that T �e.. r Cciok-
appeared personally before me this day and b�g duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal, this .gnday of f�MRF.is?.20 2�
sI
Notary
•
Seal Maria-Pia Stratta-Bennett
Moore County,North Carolina My commission expires'8 • 04-. 2.O4
Notary Public
Commission No.19992100105
My Commission Expires 8/4/2024
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020