NCC216411_FRO Submitted_20211116

1887
Downofoutiern Ines��_Vh6North Carolina
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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: Carl & Gretchen Kelly Residence
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 101 Brookfield Dr. Pinehurst
3. Latitude: 35.2239 Longitude:-79.4269 PIN: 857309264686
4. Percent Impervious: 18%
5. Approximate date that land -disturbing activity will commence: 11/22/2021
6. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): .28
8. Amount of fee enclosed: $ N/A
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 /ess than 30,000 sq. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ken Bass E-mail Address [e-mail]
Telephone Cell # 910-528-6481 Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Carl & Gretchen Kelly 910-986-1869
Name Telephone Fax #
125 Virginia Creek Dr. Same
Current Mailing Address Current Street Address
Holly Springs, NC 27540 Same
City State Zip City State Zip
11. Deed Book No. 5418 Page No. 326 (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):
GWB Construction, LLC
[e-mail]
Name
E-mail Address
120 Chesterfield Dr.
Same
Current Mailing Address
Current Street Address
Pinehurst, NC 28374
Same
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
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
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 Respons;ibte Person if an individual
or his attorney -in -fart, or if not an individual, by an ottFcer. director. partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). 1 agree to provide
corrected information should there be any change in the information provided herein.
Kenneth Bass
Type,print name
Signature
Title or Authority
Date
L .'� a Notary Public of the County of V'� � nr
State of North Carolina
hereby certify that f' l'k t:�_ —
appeared personally before me this day and being duty sworn acknowledged that the above form
was executed by him. . _ _ "l."_ _
Witness my hand and notanal seal, this .ti `Jday of Y `b Ule r►t�' V' , 20 r�•-_ �
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Notary
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