NCC231846_FRO Submitted_20230615

�,� FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of j<• SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
outhern Ines 140 Memorial Park Court
r. Northc��l�na Southern Pines, North Carolina 28387
The Nil Program txcelknce
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: 10 LI Boswell P Ia e
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address ►04 Boswell dace PivtehursF, NC i 3 -I
3. Latitude: 35. 22215 Longitude: - •L 2b�O PIN: 'i51.3102b5261
4. Percent Impervious: 31 7.
5. Approximate date that land-disturbing activity will commence: Ota 3o t ZO 2 3
6. Purpose of development(residential, commercial, industrial, institutional, etc.): Si ci e-rtH a-.1
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0• Zy
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.
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 Tj Iv1' E-mail000Ic- Address ttjlev� lal-ttudeta t,>i I devs. eo m
Telephone (CH O) (e6I 0 3q b'1 Cell# Fax#
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Ross aVtd SU Lg nv►e I va -I—
Name Telephone Fax#
manning hoick
Current Mailing Address Current Street Address
CAI rho Pr 35(6ti
City State Zip City State Zip
11. Deed Book No. 5q 3 4" Page No. 13 I (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):
t.a�;tuole gu.ildeVs Luc, their �a{iti.tdebwildvis. corn
Name E-Mail Address
�o aox 1301 l3Z NW 13roa01 St &
Current Mailing Address Current Street Address
Soc.,thevn nines Nc 2g3gg 5outhevn pines Nc 28381
City State Zip City State Zip
Telephone (q 10) (0 0 -39 b9 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.
5k - C k fr
Tye or print name Tit e�or Authority
Signature Date/y/
I, /Ornia L i Aoy nas , a Notary Public of the County of hcbre
State of North Carolina, hereby certify that T l ev Coo
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 4 day of /"i -mrS i- , 20 as
-7/b(.f .L-KL:��� �
Tonya L Thomas
Notary Public �
Moore County,North Carolina /T&t(f 2 L . i Dfl1Qf
My Comm.Expires Sept 1,2025
Seal Notary
My commission expires 9- .doas
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes❑ No❑
REVISED:January 9,2020