NCC221190_FRO Submitted_20220328

Town of < Public Works Department
140 Memorial Park Court Southern Pines, NC 28387
Telephone: [phone] Fax:[phone]
outhern Ines
'fy` rir ThehiidSrt Rrol�t FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Internationally Recognized for Program Excellence SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity greater than 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 and the Land Quality Section,
NC. Department of Environmental Quality. (Please type or print and, if the question is not applicable
or information unavailable, place N/A in the blank.)
Part A.
Multi -Tenant Retail Southern Pines
1. Project Name
2. Location of land -disturbing activity: Highway/Street/Address: US 15/501 & MURRAY HILL RD
Latitude 35.164655 Longitude-79.421572 County Moore city: Southern Pines
3. Approximate date land -disturbing activity will commence December 2021
4. Percent Impervious .39
5. Purpose of development (residential, commercial, industrial,institutional, etc.): Commercial
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.69
7. Amount of fee enclosed: $ 600.00
The application fee of $300.00 per acre plus $150.00 for each additional acre, or part thereof, and is
assessed without a ceiling amount. Any substantial revision to a previously approved, active plan is $50
per acre, or part thereof.
8. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameMOSELEY REAL ESTATE ADVISORS: BRAD L. TAYLORE-mail Address BTAYLOR q@MOSELEYREA•COM
Telephone [phone] Cell Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
BLACK, DANIEL PATRICK FAMILY
Name Telephone Fax Number
1976 ROSELAND RD 1976 ROSELAND RD
Current Mailing Address Current Street Address
ABERDEEN, NC 28315 ABERDEEN, NC 28315
City State Zip City State Zip
1693 47
11. Deed Book No. Page No. Provide a copy of the most current deed.
Page 3 of 3 1-6-21 B-81

Part B.
1. Person(s), Company(ies), or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
MOSELEY REAL ESTATE ADVISORS: William K. Moselev hmncelev(n�mncalavraa rnm
Name E-mail Address
1100 KEN ILWORTH AVE, SUITE 210 1100 KENILWORTH AVE, SUITE 210
Current Mailing Address Current Street Address
CHARLOTTE, NORTH CAROLINA 28204 CHARLOTTE, NORTH CAROLINA 28204
City State Zip City State Zip
704-927-9210
Telephor�r�_ 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 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:
William K Moseley bmoseley@moseleyrea com
Name of Registered Agent E-mail Address
1100 Kenilworth Avenue, Suite 210 Same
Current Mailing Address Current Street Address
Charlotte NC 28204
City State
Telephone_704-927-9210
. _
Zip City State Zip
Fax Number
Page 3 of 3 1-6-21 B-82

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.
William K. Moseley
Type or print name
fi
Signature
Manager
Title or Authority
Z
Date
Cnnn ip a Notary Public of the County of e
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above orm was executed by him.
Witness my hand and notarial seal, this nA day of 20ZI
Se
CON*15 H BLAKELY
NotaryPubk . NoF1h Carotin,
A4eck fpn burg County
MY{QM missi on Exofr $ lUf 15. 7Q12
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑
U �Ca t
Notary
My commission expires__,),,5
No ❑
REVISED: December 17, 2020
Page 3 of 3 1-6-21 B-83