NCC222807_FRO Submitted_20220808

Town of 61887
outhern Ines
Public Works Department
140 Memorial Park Court Southern Pines, NC 28387
Telephone:[phone] Fax:[phone]
+0p North Carolina FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
!1 , The Mid South Resort
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.
1. Project Name PINEHURST SURGICAL - 3 NORTH aka MP Medical Condos -Shell Building
2
Location of land -disturbing activity: Highway/Street/Address: PATRIOT BLVD AND PAVILION WAY
Latitude 035.177108 Longitude-079.416223 County Moore City: Southern Pines
3. Approximate date land -disturbing activity willcommence 08/05/2022
4. Percent Impervious 79%
5. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4 acres
7. Amount of fee enclosed: $ 750.00
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 No Enclosed X
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Lindsay, PE E-mail Address [e-mail]
Telephone [phone] Cell 910-920-7661 Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Morganton Park Realty, LLC 910-215-2646
Name
Telephone
5 First Village Dr.
Current Mailing Address Current Street Address
Pinehurst, NC 28374
City
State Zip
11. Deed Book No. 5210
age No. 279
Fax Number
City State Zip
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.
Morganton Park Realty, LLC cgregg(4)pinehurstsurgical.com
Name
5 First Village Dr.
Current Mailing Address
Pinehurst, NC 28374
City State
Telephone [phone]
E-mail Address
Current Street Address
Zip City State Zip
910-215-2646
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
Current Mailing Address
E-mail 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:
Charles Gregg
Manager [e-mail]
Name of Registered Agent E-mail Address
5 First Village Dr
Current Mailing Address Current Street Address
Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] 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,
Charles Gregg
4T,..Ype,orntnai-ne
gnature -
Manager, Morganton Park Realty, LLC
Title or Authority
Date
I, L a Notary Public of the County of (r IDme—
State of North Carolina, hereby certify that marl Q S appeared
personally before me this day and being duly sworn acknowledged that the abaolrrn was executed by him.
Witness my hand and notarial seal, this I day of Aat4 20 /) �_
Seal
FOR TOWN USE ONLY:
LORI C MORGAN ' " V
Notary Public, NQTth Carolina
Moore County
My Commission Expires
December 20, 2025 [_ ff��
My commission expires 'Dec"6er p V , r� )'o as
Covered by 5/70 Provision
Yes ❑ No ❑
REVISED: December 17, 2020
Page 3 of 3 1-6-21 g-$3