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HomeMy WebLinkAboutNCC231687_FRO Submitted_20230606 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Town of 0 6137 0100,!. SEDIMENTATION POLLUTION CONTROL ACT Public Works Department (I11outhern Ines 140 Memorial Park Court North Carolina Southern Pines, North Carolina 28387 .". r. The Mid South Resort Telephone: 910-692-1983—Fax: 910-692-1085 Intcrnammalh ilecognind tor Ptvgram Excellence 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: Philip and Tiffany Bailey Residence 2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines Street Address 24 Birkdale Dr. Pinehurst NC 28374 3. Latitude: 35.2197 Longitude: -79.4140 PIN: 857311653134 4. Percent Impervious: 27.4% 5. Approximate date that land-disturbing activity will commence: 6/7/2023 6. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): .35 8. Amount of fee enclosed: $ N/A 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 sq. ft. of disturbance. 9. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Kenneth Bass E-mail Address Ikbass36@hotmail.com Telephone Cell# 910-528-6481 Fax# 10. Landowner(s) of Record (attach accompanied page to list additional owners): Philip and Tiffany Bailey Name Telephone Fax# 68 Dunarven Ln. 68 Dunarven Ln. Current Mailing Address Current Street Address Pinehurst NC 28374 Pinehurst NC 28374 City State Zip City State Zip 11. Deed Book No. 5815 Page No. __597 (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): GWB Construction, LLC Ikbass36 c@hotmail.com Name E-mail Address 27 Chestertown Dr. 27 Chestertown Dr. Current Mailing Address Current Street Address Pinehurst NC 28374 Pinehurst NC 28374 City State Zip City State Zip Telephone 910-528-6481 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 knowtedge and belief and was provided by mo under oath (This form must be signed by the Financially Responsible Person if an individual or h4 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. illert,--,.•/Ala,gAr.3,,,r,„_ Typaix print name Tile or Authority >— , _ Z6_ LPL-t Signature Date I_ g►` 1 Qi- 8fl n' /►refe- .a Notary Public of the County of ala// State of North Carol, hereby certify that f' rl P„r 6S appeared personalty before me this day and being duly sworn acknowledges; that the above form was executed by him. Witness my hand and notarial seal,this _ V day of Alitti, . 20 3 3 .4":„0".L..1.p 44\ . Y s E. . i f Notary Seal '.-( 8 LPL ' `'%S� •., - i�� My commission expires f)'I 4t'J124,9 ,5 fOR town us&OM-Y. Covered by 5/70 Provision 'Yes 0 No 0 RIMED.J41.0f1 f.2020