NCC232320_FRO Submitted_20230803

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—TM; FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Mom of SEDIMENTATION POLLUTION CONTROL ACT
LI (, Public Works Department
but ern ines 140 Memorial Park Court
Iti �^ hLucia Southern Pines, North Carolina 28387
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lw*ruim.y Hrav4naed 6r rk,g:.rt r_u r Telephone [phone]—Fax [phone]
An
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 Lephart Residence
2 Location of land-disturbing activity County Moore City or Township Southern Pines
Street Address 114 Heatherhurst Place Pinehurst
3 Latitude 35 220537 Longitude -79.424327 PIN 857310352474
4 Percent Impervious 11.3%
5 Approximate date that land-disturbing activity will commence 08 07.2023
6 Purpose of development(residential commercial industrial institutional, etc ) residential
7 Total acreage disturbed or uncovered (including off-site borrow and waste areas) .3 acres
8 Amount of fee enclosed S
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 2i° 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 Lily Camina-Vick Email Address [e-mail]
Telephone [phone] Cell# 910.690.2249 Fax# [phone]
10 Landowner(s)of Record (attach accompanied page to list additional owners)
Scott Lephart 859.537.5787
Name Telephone Fax#
833 Willow Oak Circle 833 Willow Oak Circle
Current Mailing Address Current Street Address
Lexington KY 40514 Lexington KY 40514
City State Zip City State Zip
11 Deed Book No 5747 Page No 27 (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 sheets
Camina Design & Construction [e-mail]
Nam
E-mail Address
165 Fox Hollow Court 165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst NC 28374
28374 Pinehurst NC
City State Zip City State Zip
Telephone [phone] Fax# [phone]
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
Jose' Camina [e-mail]
Name of NC Registered Agent E-mail Address
165 Fox Hollow Court 165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax# [phone]

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.
L:�` C�•�., -� :� � -P 05.)1.
Type dr print name Title or Authority
0'1- .201-3
Sig re Date
I, -"S`°` g• ria- , a Notary Public of the County of A ,r
State of North Carolina, hereby certify that L; lam�{{ Ccrmiruck..-V;Le
appeared personally before me this day and bein6 duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal, this o2" day of , 20 a3
\0,IINEN0���4,
01ARy = Notary
Seal
,so PUMP My commission expires ./a9/ass
p9�,CIo'ut41,
10
FOR TOWN USE ONLY
Covered by 5/70 Provision: Yes❑ No❑
REVISED January 9 2020
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