NCC216900_FRO Submitted_20211214

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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: 160 N Brackenfern Lane
2 Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 160 N Brackenfern Lane
3. Latitude. 35,1954 Longitude:-79,4159 PIN: 857200567216
4. Percent Impervious: 28%
5. Approximate date that land -disturbing activity will commence: 12/15/2021
6 Purpose of development (residential, commercial, industrial, institutional, etc.): Residential) SFD
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas):~
8. Amount of fee enclosed: $ N/A
The application fee is $300.00 for the first acre plus $160.00 for each additional acre, or part thereof.
The revised plan review fee is $60 for each submittal after the 2nd review.
Any substantial revision to a previously approved, active plant is $60 per acre, or part thereof.
No Fee for Minor Construction Activities less than 30 000 sct ft of disturbance
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lee Forbis E-mail Address [e-mail]
Telephone Cell # 910-308-1984 Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Forbis Land Development LLC 910-308-1984
Name
40 Quaker Ridge Rd
Current Mailing Address
Pinehurst NC 28374
City State Zip
11. Deed Book No. 5571 Page No
Telephone
40 Quaker Ridge Rd
Fax #
Current Street Address
Pinehurst NC 28374
City State Zip
165 (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):
Forbis Land Development LLC
forbisland@gmai(.com
Name
E-mail Address
40 Quaker Ridge Rd
40 Quaker Ridge Rd
Current Mailing Address
Current Street Address
Pinehurst NC 28374
Pinehurst NC
City State Zip
City State
Telephone [phone]
Fax #
28374
Zip
2 (a} If the nciaily Responsible Party is not a reside of North Carolina, give name and street address
of the desig ted North Carolina Agent -
Name of
Current Mailing
E-mail Address
Current Street Address
City Stat Zip City State Zip
ephone
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 E-mail Address
Current Mailing Address Current Street Address
City State
Telephone
Zip City
Fax #
State Zip

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.
Lce �I
Type qr print name
�f
Signature
W A011�-..
Title or Authority
Date
a Notary Public of the County of
State of North Carolina, hereby certify that t"'r'6,
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 (jf day of 20.
AMIE N PATTERSON
NOTARY PUBLIC
MOORC COUNTY
STATE OF NORTH CAROLINA
Y COMMISSION EXPIRES: 11 -,,A )""Iq
beal
FOR TOWN USE ONLY
Covered by 5170 Provision: Yes ❑ No ❑
Notary
My commission expires I -D- 9--J -�c'�9
REVISER January 9. 2020