NCC215789_FRO Submitted_20211018

�Hr FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of e e SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
t1fern�s 140 Memorial Park Court
f'u�0 NorlhCarofim Southern Pines, North Carolina 28387
, The Mid South Resort
larwationally RecoRnimd for Pmkirur Emilence 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: _ Gex Qaf'dt kelsi denel _e
2. Location of land -disturbing activity: _ f County: Moore Cityyor Township: Southern Pines
n Street Address 33 l[�`�1�-tOthLl atr�ee_f- 1 7 rhLV�
3. Latitude; _^ ._ Longitude: �" � PIN: 3%3COcR376%
4. Percent Impervious: 1 -7 a/c,
5. Approximate date that land -disturbing activity will commence: ra�iD7�2�
6. Purpose of development (residential, commercial, industrial, institutional, etc.): �t5frr
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas):. �a
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 totIN contact should erosion and sediment control issues arise during land -disturbing activity: r
Name I (1 4tii1' t P- E-mail Address W) I i @P h 1�6��-(?V des ir, 1) bilid,C��`
Telephone [phone] Fr Cell d# 919 -Y?7- 6Y,,P Fax # / )+
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax #
15,09 V4T0 r+o1 t "Cr-
Current Mailing Address
56-n
City State Zip
Current Street Address
City State Zip
11. Deed Book No. 55'3(- Page No. 193, -17 "_ (Provide a copy of the most current deed).

IOrta 0
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):
Run-Keq Desian"_?-)urIrl W1,[IahoA4ydgAranburld•c0m
Name t E-mail Address
`6 Clark— (2+
C rent Mailing Address C ent Street Addre s
�j P�
it Y1�c� _ _ Ale
�?`f" ---t� /17 � Clr� - JVC-- o2?77'1
City State Zip City State Zip
Telephone q m - 04— 2! q' 6� Fax # A
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State
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
Current Mailing Address
E-mail 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.
Type o print na(nq r Title or Authority
/0// 3 Z.L
Signature Date
I, ,1� • � �f�� , a Notary Public of the County of -C ,
State of North Carolina, hereby certify that
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. pp
Witness my hand and notarial seal, this /� day of&hi�er , 20 0Z
MADONNA NEM EUON ylYN�
Nctary Public, Ncrth Carolina
omCounty
My Cmis!on Expires Notary
My commission expires &k Q&;='
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED: January 9, 2020