NCC216530_FRO Submitted_20211122

Town of(I
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The Mid South Resort
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FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
Project Name: HAMMERSCHMIDT
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 16 MASTERS RIDGE PLACE, SOUTHERN PINES, NC 28387
3. Latitude: 35.1873
4. Percent Impervious: 36.3%
Longitude:—79.42635
PIN: 857214239219
Approximate date that land -disturbing activity will commence: 11/15/2021
6. Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): .41
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.
74
10
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jots Potter E-mail Address [e-mail]
Telephone [phone]
Cell # same
Fax # n/a
Landowner(s) of Record (attach accompanied page to list additional owners):
Dave and Donna Hammerschmidt 910-987-7776
Name Telephone
205 Hunters Trail 205 Hunters Trail
Current Mailing Address Current Street Address
SouthemPines NC 28387 SouthemPines NC
City State Zip City
n/a
Fax #
28387
State
Zip
11. Deed Book No. 5604 page No. 522 (Provide a copy of the most current deed).

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):
Masters Properties, Inc. [e-mail]
Name E-mail Address
25 Masters Rdg 25 Masters Rdg
Current Mailing Address Current Street Address
SouthemPines NC 28387 Southern Pines NC 28387
City State Zip City State Zip
Telephone [phone] Fax # n/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 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
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Jon Potter President, Masters Properties, Inc.
Type or prir amq Title or Authority
//- /Y- 2 I
Date
I, -161� I16 L- -%hOMAS , a Notary Public of the County of Moo re
State of North Carolina, hereby certify that T011 f 0iff- '
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed n him. day of - /t�YetfibW 20AUa
Witness my hand and notarial seal, this y ,
Tonya L Thomas
Notary Public
Moors County, North Carotin
[My Comm. Expires 1 2na
Seal
FOR TOWN USE ONLY:
Covered by 5R0 Provision: Yes ❑ No ❑
h
Notary Q
My commission expires -1 —l " a?6Q 5
REVISED: January 9, 2020

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