NCC231287_FRO Submitted_20230502

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
LIouthern Ines 140 Memorial Park Court
,;,.• ' rsonhCaroana Southern Pines, North Carolina 28387
laternabortally yea for Program bccelknce 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 398 W NEL.J J ERs Eq AVE-uuE
2 Location of land-disturbing activity. County. Moore City or Township: Southern Pines
Street Address 3,8 W NCwJE4.5Ey v6NUF, Sou1r+€ / )9N6-,5, NC. z8387
3. Latitude. 3S • 1811 Longitude 79 • 3 7 L PIN• 8S82.18 ty z 2-39
4 Percent Impervious: 5'8 %,
5. Approximate date that land-disturbing activity will commence: A P 4L 2.D 23
6 Purpose of development (residential, commercial, industrial, institutional, etc ): 2 es t DENT-t Prt-
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas) G• t 2- AG
8. Amount of fee enclosed. $
The application fee is S300.00 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 so. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name -3 uSTJ 13 [- $1 94 15 E-mail Address suPgigierAtte,rtESdre7114Sa4441 1-4-i mats c �
Telephone 9( - 6 7 3 -0 6 'c Cell# Fax#
10. Landowner(s)of Record (attach accompanied page to list additional owners):
C H P DcvELoPM.ENT-, LLC
Name Telephone Fax#
16908 H ocgc y Bovt.E,IARD SAt-tC
Current Mailing Address Current Street Address
I1wJrEesvILLE nl C z 8078 5 it1E
City State Zip City State Zip
11. Deed Book No. 5 / Page No. LI Z-I (Provide a copy of the most current deed)

Part B.
Person(s) or firm(s) who is financially responsible for the land-disturbing activity
(Provide a comprehensive list ofall responsible parties on an attached sheet):
SvPfRio(� Or fk.5 OF TM-ESA Lle SuPERtoNanE.6OFTHS5A0i)Hii.L.S@GNIAt�.Co►A
Name E-mail Address
I2.O McKE14ZlE5 MILL ROAD SAr+E
Current Mailing Address Current Street Address
VAST END N C 2-7376 5 t- g
City State Zip City State Zip
Telephone 910- 6 73- o6Oo 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.
JV5 TIN 1-16RRI5 RESPoPSJ .E PER..5oN
Type or pri t name Title or Authority
/ C Z - 2- 3
• nature Date
! � .�~ _r. ry Publ' e County of rY7( ;T
h rolina her• . certifythat l 1,�-C I'1
State of No � 1
appeared pe nally before me this day and being duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal, this I aday , 20
f tacey StauferJ
Notary Public
Moore County
North Carotin
_`My Commission Ellres
Notary
Seal 7d-6/
My commission expires
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes❑ No ❑
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, 6,h Floor(Office 640K)
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 122.22]
Per NC General Statute 143-215.68(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 all boxes to indicate your agreement):
�Y 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.
1/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.
In/will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
VsIf the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
ermit are met on the project at all times.
I hereby request coverage under the NCG010000 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. Q
Name of Project(must match Ala): 3 l , New 3 e/s.ey /9 vv ,
Specific Lot Numbers(must match Alb):
Legally Responsible Organizational Entity(must match 81): Scf er.8or ►' s of- S IL.1 i f, : z. C_
Legally Responsible Person (must match 82& 83): Tcn 5 t. to - - i S
Title of Legally Responsible Person (must match B3b): g25pa n S. b 1 e ( e,e s04.)
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number:
01-1/4,.. -3 9/.03
Signa • • egally esponsible Person or Authorized Individual Date
* 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 NCG010000 permit.