NCC231265_FRO Submitted_20230501

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of toed
1_887 SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
outhern Ines 140 Memorial Park Court
it' • f' The^W South Southern Pines,North Carolina 28387
Imcrnvanaly Recognized for Program EeceU,n°e 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.
1. Project Name: i � f%ct9ie PO ill-tomb
2. Location of land-disturbing activity: County: Moore, City or Township: Southern Pines
Street Address Ii5 t;cugfe ka0int- LOI SOuthervi Pines, NC 28321-
3. Latitude: �5, E'3 5ii'1 QQ Longitude: " 9.1•I I9 t i o PIN: Q57/.ZG04 Zf-la OZ
4. Percent Impervious: 1 a`Ie 5. Approximate date that land-disturbing activity will commence: Ai v 1 Z 0 22
6. Purpose of development(residential,commercial, industrial, institutional, etc.): rest de rib Ci I
7. Total acreage disturbed or uncovered(including off-site borrow and waste areas): o 'Z
8. Amount of fee enclosed: $ NI
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 sa.ft.of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tyler Gook E-mail Address tylereW-htUclebuildasaeoivi
Telephone (C1 10) Q c --2,61 ldl Cell# Fax#
10. Landowner(s)of Record(attach accompanied page to list additional owners):
Et-orre L-Gln301 ( 4) g31 -1-P3g
Name Telephone Fax#
236 Ne occon (3lvd Unit"831-
Current Mailing Address Current Street Address
Stucivt- EL 3496119
City State Zip City State Zip
11. Deed Book No. 56)03 Page No. (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):
Lt2lhtU4C '�U► �d��s U,i,c 1-1116 1cth tudebU,; idexs.corn
Name E-mail Address
PO UOx 1301 'Lco N Ocolictt St
Current Mailing Address Current Street Address
SOLO-0011 elrieS NC- 25388' f71 ie- NC- Z83 -1'
City State Zip City State Zip
U
Telephone -I 1 o-601 o 3 g b 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 E-mail Address
Current Mailing 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.
it/ler C-q<)L 0Jher
Type or print name Title or Authority
Signature Date
I, 5 fini- ANQrl- , a Notary Public of the County of (r�.0r�r-f_
State of North Carolina, hereby certify that ` lf.---niter Do f /
appeared personally before me this day and bein'duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal, this 15 day of Fe-bru.a43 , 20 �1
15`"o.Coc\ ( 4
.•ll\0449N q V
•N O TA,O
• M Co m.Exp;s• = Notary
Seal▪ : A I _��:
0'•. Ug L I G • My commission expires '
- 0• .•a
�'�,,,COrUN11;.•.
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes❑ No 0
REVISED:January 9,2020