NCC220950_FRO Submitted_20220307

LA RSA
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town ofred1887 SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
�,Upuffiern ll1eS 140 Memorial Park Court
I NorthCamlina Southern Pines, North Carolina 28387
/t 6 The Mid South Resort
lnternaUonalyRecognized for lhogrmnExcellence 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.
Project Name:
rs-e, n Yr o i e G+
2. Location of land -disturbing activity: County: Moore`` City or Township: Southern Pines
Street Address I O M 0 h +-,o +L2l 1 1 Izr !l?
3. Latitude: 15 , 27-00 Longitude: 19,y l'L PIN: 9,G"15 Q-4 0DW �
4. Percent Impervious: 1-4 . 00 V e
5. Approximate date that land -disturbing activity will commence: 2� Z02�
6. Purpose of development (residential, commercial, industrial, institutional, etc.): re S,l der1
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): D . 1 (2) 2- ftr res
8. Amount of fee enclosed: $ 0 • O O
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 sci. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name r11'10Ax1cI E-mail Address !�;I `VOL S--Q+A'l n-fi O-Cl0
Telephone O �' g 3 Z Cell # ` Fax # N /
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Mftr-}i n LArst, n
Name Telephone Fax #
06 � S P 1a,_rN VAi Vy-, Z),r-; v-e
Current Mailing Address Current Street Address
>w-A- -ems ?i rveS t3C 2Q3`� � GDvt fern P\ fXf,S Q 2 Sae �_
City State Zip City State Zip
11. Deed Book No. 4A 23 Page No. (Provide a copy of the most current deed).

WartB.
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):
*t 1 a _x--vd 1N oo Vsr- a bb H Z Y - i
Name
Current Mailing Address
B>nehtACS+ N C 793"+9g
City State
nn Zip
C � �
Telephone 'b ` Q CO fib
N'
ijr'�
E-mail Address �J h uvv"-e 5 - `4 `'
4-+p N N jg Iry a_o1 5 fire -e-
Current Street Address
City State Zip
Fax #- N Ar
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
Current Mailing Address
City
Telephone
State
E-mail Address
Current Street Address
Zip City State
Fax #
Zip
(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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
-e (� fir` 0 -t-
Type�rpnt name Title or Authority
a#ure `) 0�-ir'1 - Z (� t Z b Z
Date
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1, a Notary Public of thq County of o /-'e_
State of North Carolina, hereby certify thata
appeared personally before me this day and being duly sworn ackno edged that the above form
was executed by him. u
Witness my hand and notarial seal, this 2 D day of 20
Sic,! Du;;,�,rj T
NCTA; : I PU3LIC
Moore Cou^ty
North Carc!ins
'MY Commissior Expires Marrh 1d. ^n�? Notary
My commission expires L4E 20 Z 3
FOR TOWN USE ONLY:
Covered by 5170 Provision: Yes ❑ No ❑
REVISED: January 9, 2020