NCC220827_FRO Submitted_20220221

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Town of
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North Carolina
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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:. Langdon and Raven Caddell Residence
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 4 Woodward Pi. P'inehurst
3. Latitude: 35.2333
Longitude:-79.4127 PIN: 857404608122
4. Percent Impervious: 23.7%
5_ Approximate date that land -disturbing activity will commence: 3/1/2022
& Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): -29
8. Amount of fee enclosed: $ NIA
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 scl, ft, of disturbance.
9_ Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Hope Maness E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Langdon and Raven Caddell
Name
153 Mine Rd.
Current Mailing Address
Carthage NC 28327
City State zip
910-639-4324
Telephone
Same
Current Street Address
City
Fax #
State
Zip
11 _ Deed Book No. 5574 Page No. 515 (Provide a copy of the most current deed).

rt B.
1
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):
Eastcoast Development Group, LLC [e-mail]
Name E-mail Address
PO Box 3519 25 Dowd Cr_
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax #
(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 E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City State
Fax #
Zio

ie 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 attomey-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. provide herein.
Type or pent name Title or Authority
klqrr�--)v 'q C� 2 1 17 2�
SignaG4 Date
aj4Vtary Public of the County of
State of-No4 Carolina, her by certify that
appeared personally before me this day and being buly sworn acknowledged that the above form
was executed by him. y
Witness my hand and notarial seal, this 0' day of , 20 F 1
v'�A�zl A
Kay Howery
NOTARY PUBLIC
Moore County, NC
My Commission Expires September28, 2026 Notary
Seal�9�g
My commission expires
FOR TOWN USE ONLY:
Covered by WO Provision: Yes ❑ No ❑
REVISED: January 9, 2020