NCC215838_FRO Submitted_20211025

Town of rt%`"
outhern Ines
._ %6
4 �" North Carolina
11 The Mid South Resort
Internationally Recognized for Program Excellence
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
140 Memorial Park Court
Southern Pines, North Carolina 28387
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: 129 Chesterfield Drive
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 129 Chesterfield Drive, Pinehurst, NC
3. Latitude: 35.215370 Longitude:-79.421940 PIN: 857314339577
4. Percent Impervious: 15%
5. Approximate date that land -disturbing activity will commence: 23 SEP 2021
6. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): .12
8. Amount of fee enclosed: $ 0
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 Warren "Ducey" Dabbs E-mail Address [e-mail]
Telephone Cell # 910.279.7703 Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Dabbs Brothers LLC 910.295.9000
Name Telephone Fax #
Po Box 2032 126 Cypress Circle
Current Mailing Address Current Street Address
Wilmington NC 28402 Southern Pines NC 28387
City State Zip City State Zip
11. Deed Book No. 5662 Page No. 163 (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):
Dabbs Brothers LLC infoQdabbsbrothers.com
Name
PO Box 2032
Current Mailing Address
Wilmington NC 28402
E-mail Address
126 Cypress Circle
Current Street Address
Southern Pines NC 28387
City State Zip City State Zip
Telephone [phone] 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
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 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.
_ Warren 'Ducey" Dabbs
Type or pint name
Signature
Owner, Dabbs Brothers, LLC
Title or Authority
11 /30/2020
Date
----------------------------
1, a Notary Public of the County orA�6,4Ql e'°d
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.
Witness my hand and notarial seal, this _ day of _�/Qr� j 20 14
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ Na ❑
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Notary
My commission expires _ 1-11 'Zd1,,l
REVISED: January 9, 2020