NCC241011_FRO Submitted_20240404

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Southern Public Works Department
140 Memorial Park Court
Pines 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 N/A in the blank.)
Part A.
1. Project Name: Hawthorne at Southern Pines
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address Off of Intersection of St Joseph Rd and US HWY 1
3. Latitude: 35.201201 -79.376126 Portions or: 12,858667500,859208200882,
Longitude: PIN: 858300709512,858207694691.856200882301 to be recombined
4. Percent Impervious: 52.7%
5. Approximate date that land-disturbing activity will commence:
6. Purpose of development (residential, commercial, industrial, institutional, etc.): Multifamily Residential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 27.10 ac
8. Amount of fee enclosed: $ 4350.00
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 Philip M. Payonk E-mail Address ppavonk(chrplivinq.com
Telephone [phone] Cell#704-819-7005 Fax#
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Southern Pines Apartments, LLC 336-553-1700
Name Telephone Fax#
806 Green Valley Rd, Ste 311
Current Mailing Address Current Street Address
Greensboro , NC 27408
City State Zip City State Zip
MP 20
11. Deed Book No. a copy Page No. 95
g (Provide of the most current deed).

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):
Hawthorne Residential Partners [e-mail]
Name E-mail Address
806 Green Valley Rd 806 Green Valley Rd
Current Mailing Address Current Street Address
Greensboro NC 27408 Greensboro NC 27408
City State Zip City State Zip
Telephone [phone] 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#

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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Type or print name Title or Authority
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Signature Date
I, 53rlltnc 146 50Y\a( �', a Notary Public of the County of Yu 1. fd
State of North Carolina, hereby certify that 1VV-1�Ytp • A)Ak-AOr\ -
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. _
Witness my hand and notarial seal, this 5 day of \21(1A CLYZ1 , 20 a -
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NOTARY - Notary
PUBLIC
Seal - .—•-.. -
My Comm.Exp. My commission expires ap a.-7
Nov 20,2027 -
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FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9, 2020