NCC230394_FRO Submitted_20230213

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FINANCIAL RESPONSIBILITYIOWNERSHIP 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.
Project Name:
_FCAROL, 12-ZL
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 2 56 MULL 1007A 12 1i9.%vE I CAIA"AGE N C 7-8327
3. Latitude: 3 5. Z Z Bg!
4. Percent Impervious
Longitude: ^79. 37&9 PIN: 8,58300771915
5. Approximate date that land -disturbing activity will commence: Dec eme)E2 Z o 2.2.
6. Purpose of development (residential, commercial, industrial, institutional, etc.): RC--i DEN'raAs.
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
0.4 ! 4c
8. Amount of fee enclosed: $ _
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.
N_Q Fee for Minor Construction Activities less than 30,000 so. ft, of disturbance.
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name L.ESLie GA-oWE.5 E-mail Address �°�—S�iC rov6.5��i�hantGS•Gom
Telephone 9 t O ' 4186 — 4 Cell #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
DFC REVOLVER LLc 910-496-49!,4
Name Telephone
Fax #
Fax #
136606AW44A A"X qf C1944.0Stlzj5,j7lZ4 6 A".E
Current Mailing Address Current Street Address
Patire VEDRa FL 328o7- 5ArtiE.
City State Zip City State Zip
11. Deed Book No. 5&5Lf Page No 3a7 (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):
DE-C-AM Fi N'QeRs l��r�. 5 f � tL 1 e51 , eg rove,5 LIP I h n rM e5. Coy%
Name E-mail Address
i 1-761 P,4,w p Hw S AME _
Current Mailing Address Current Street Address
,ACV_5nNvtwE FL. 32256 SAKE
City State Zip City State Zip
Telephone 1 4&(z_qg6y 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
Current Mailing Address
E-mail 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.
Le:sw I` G izavE5 Divt siiso Pg&sj t7FNT
y or print name Title or Authority
gnaturer...._.,_....__.�...----------- Date--------------------
1, 1(.rna ,-a L 6r-ee � � a Notary Public of the County
State of North Carolina, hereby certify that L � I e _ l Ne S
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 day of DI tal-Y l t , 20
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FOR TOWN USE ONLY:
Covered by 5170 Provision. Yes ❑
No ❑
otary
My commission expires
REVISED: January 9, 2020