NCC230733_FRO Submitted_20230320

Torn of
outhern ines
The SWA"'%on
I,+axwfeyly Recomumd for PrV= Fxcmena
FINANCIAL RESPONSIBiILITWOWNERSHIP 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:
-rCAROL I2,-006
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 1 6 5 N Lr"I eJ a 4 2 17 R1 v ECqa.18466 C, 2-8317
3. Latitude: 3 5. 7- Z% Z Longitude: --79. 3796 PIN: 8 S83 ❑0 613 74 46
4. Percent Impervious: 13 �o
5. Approximate date that land -disturbing activity will commence:
6. Purpose of development (residential, commercial, industrial, institutional, etc.):
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
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 $60 for each submittal after the 2nd review.
Any substantial revision to a previously approved, active plan is $60 per acre, or part thereof.
No Fee for Minor Cansrrucrion 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 LE5L.IF GRoveS E-mail Address les1:?-. rove,3E'JrwrnT;n4e5I'pme5',60M
Telephone 9 Jo - 4 $ 6 - 4 8 6y Cell #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
D r C REvo4vp—f2 IL LL C _
Name Telephone
13rAD w J?A55 VJLLA ar ttt $LD 5 5+Cz-Y
Current Mailing Address
PorvMVEDIZ4 FL, 32a8Z,
City
State Zip
SAINkF
Current Street Address
5AMS.
City
Fax #
Fax #
State Zip
11 Deed Book No. 5 8 S "f Page No. 387 (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): [�
DREAM f7wDL-k5 HOMES. LLC 1P5, i t r6 v Ps @ +`lrea,m '+n ers �or� eS. cam
Name E-mail Address
3-109 RAP-Fo0 Q.eAi). SutSAME
Current Mailing Address Current Street Address
F04E'rrF_vIuLC-_ N G Way SAME
City State Zip City State Zip
Telephone 914 -- 4 g 4 — 4 $ 4't 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
Current Mailing Address
City State
Telephone
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
Telephone
E-mail Address
Current Street Address
Zip City State
Fax #
Zip

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 5 L I G 6 RZV-,C-s
Typq or print name
ViV51 atQ PIZGSI of fU7—
Title or Authority
a� 14
Date
I. " 1 r L 6r"OAl a otary Public of the County of f �Irli✓ r f�
State of North Carolina, hereby certify that z-'a I� Firm
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 , 20 3
Ar.• •'• •=
G1e46UBL%cND
• 2
FOR TOWN USE ONLY:
Covered by 5170 Provision: Yes ❑ No ❑
Alva
MMA
My commission expires
REVISED: January 9, 2020

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 611, Floor (Office 64.01K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Per NC General Statute 143-21.5.6B (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check aid boxes to indicate your abreemen;.:):
[D I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
Q The information submitted in this NOI is; to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
0 I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
Q If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ensure that all conditions of Parc II of the
perrnit are rnet on the project at all times.
b� I hereby r equest coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): --T C ICE C) L 1 a - d o 1p
Specific Lot Numbers (must match Alb): I a ` V O (-0
Permittee (must snatch Bl): OVUM tnd cys rn ) LLc
Legally Responsible Person (must match B2 & B3): Leslie Groves
Title of Legally Responsible Person (must match B3b): V I'S I eSI d LnT
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Ph
Number: 910-486-4864
Signature of Legally)T&ponsible Person or Authorized Individual
F.
1-J.
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCGO10000 permit.