NCC215414_FRO Submitted_20210930

Town of
outhern nes , H
r, North Carolina
'; �1t The Mid South Resort
Internationally Recognized for Program F-wdence
Public Works Department
140 Memorial Park Court Southern Pines, NC 28387
Telephone:[phone] Fax:[phone]
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity greater than 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 and the Land Quality Section,
NC. Department of Environmental Quality. (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 Ravensbrook Phase 2
2. Location of land -disturbing activity: Highway/Street/Address: Amelia Drive
Latitude 35.2344 Longitude 79.4009 County Moore City: Southern Pines
3. Approximate date land -disturbing activity willcommence June 1, 2021
4. Percent Impervious 13.76
5. Purpose of development (residential, commercial, industrial, institutional, etc.): Residentail
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25 acres
7. Amount of fee enclosed: $ $3,900
The application fee of $300.00 per acre plus $150.00 for each additional acre, or part thereof, and is
assessed without a ceiling amount. Any substantial revision to a previously approved, active plan is $50
per acre, or part thereof.
8. Has an erosion and sediment control plan been filed? Yes No Enclosed X
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Lindsay E-mail Address [e-mail]
Telephone Cell 910-920-7661 Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Ravensbrook LLC 910-639-1065 [e-mail]
Name
2 Regional Circle
Current Mailing Address
Pinehurst NC 28374
City
State Zip
Telephone
SAME
Current Street Address
SAME
City State
Fax Number
Zip
11. Deed Book No. Page No. Provide a copy of the most current deed.
Page 3 of 3 1-6-21 B-81

Part B.
1. Person(s), Company(ies), or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Ravensbrook LLC [e-mail]
Name
E-mail Address
2 Regional Circle 2 Regional Circle
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State
Telephone [phone]
Zip City
Fax
State
Zip
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
Current Mailing Address
E-mail 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 Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number.
State
F
Page 3 of 3 1-6-21 B-82
011

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.
Colin Webster
Type or print name
Manager
Title or Authority
Date
a Notary Public of the County of X o/ _z
State of North Carolina, hereby certify thatdappeared
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_�z day of �{%P . 20 `
FEIL0%2025
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑
W�'*21,
M 0 ON 1.0 0.11A
WAR
My commission expires 4�� /i _ , z-,;2U2z5�
No ❑
REVISED: December 17, 2020
Page 3 of 3 1-6-21 B-83