NCC220826_FRO Submitted_20220224

Tonnof`/Yl�cf(IN�r
ou ier n Ines
s. A ' , .S' North Carolina
ii The Mid South Resort
Internationally Recognized for Program Excellence
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 N/A in the blank.)
Part A.
1. Project Name: Drew and Tricia McNeill Residence
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 130 Chesterfield Dr. Pinehurst NC 28374
3. Latitude: 35.2163 Longitude:-79.4205 PIN: 857314433977
4. Percent Impervious:_28.91
5. Approximate date that land -disturbing activity will commence: 2/28/2022
6. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): .24
8. Amount of fee enclosed: $ N/A
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 s . ft, of disturbance.
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kenneth Bass E-mail Address Ikbass36 hotmail.com
Telephone [phone] Cell # Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Cameron D. and Tricia A. McNeill
Name
510 Legacy Lakes Way
Current Mailing Address
Aberdeen NC' 28315
City State Zip
828-736-2180
Telephone Fax #
Same
Current Street Address
City
State
Zip
11. Deed Book No. 5734 Page No. 402 (Provide a copy 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):
GWB Construction LLC Ikbass36(@.hotmail com
Name E-mail Address
27 Chestertown Dr. Same
Current Mailing Address Current Street Address
Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax #
Z (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 #

2- (a) 1" the Fir-inciniiy ko`,pomak,de. 1,�jrty is riot ;j rt*iLX-rj1 of North Caroiin,-1,
Of the &Fi.qriled North Caroli-qaGent ARivi) n,'tm,,, and street
Narric
L-mil Ac1dress
Currant Mal'ing Address
Current S:rr-,Pt Address
City
"'ate Zip Cit-V
Fax Nkirnbr�r
State 7ir)
(b) If the Ftnanr�-iily Responsible Parly is a P,11filefrhip or other fjorse.-I C-119-:i9in,9 in under an
a,sumprf name, attach .acopy of the Certificate Of AssiAnne(l Name. If lzht,� Financially ReLsponsible
Party is a Corporaion. qiVe. r`J`nc-- 31-1d Weet Ciddress of the Pegistored Agent,
iZ"frWof Fil—mi-M-Pred- Agent
CUTICA N11alling Address
City
Toleptionc.
Cijrrent,Stri�pt Adrrens
State ZiD
F,ax NL. rn
Thp above? ir,,foirn;j;jrjr, 1.,5 tart? and correct to the best of my knOWIC-dgeand bclief and iva!, provided
by file under oath (I his form must be sign
ed by the Finari�jcjfly ResK)m5ible Person if an individual
or his attorney -in -fact, Of if riot an ftieivldut'I, by an officer. director. partner. or registered agent with
the authcritY to PXeCutP iris-trijrrierit5 for the Financially Responsible Person). I agree to provide
cO,'rL'Ctcd inf0ft"i4tior, itioruld there be any change in the information provided herain,
Ken Bass
"fvp"r;)nnt name
TAIP of Authority
Signature', S _ Date
j
-�ubljc of a Notary I the County of
StatP of North Carolinz-1, hereby certify that appeared
pprsor,Aly before me this day and being duly sworn ncknowlfdqid that the above form was
(-xecilted by him.
Witness tny hand and noWrial -seal, thisday of i,
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