NCC222248_FRO Submitted_20220620

Town of ad1!<8T
outliern nnes
Public Works Department
140 Memorial Park Court Southern Pines, NC 28387
Telephone: [phone] Fax:[phone]
North C°na FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
li The Mid South Resort
Internationals Recogniwd For Program Excellence
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity greater than 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 and the Land Quality Section,
NC. Department of Environmental Quality. (Please type or print and, if the question is not applicable
or information unavailable, place N/A in the blank.)
1. Project Name Pine Ridge Parkway
2. Location of land -disturbing activity: Highway/Street/Address: 10695 US 15-501 Hwy, Southern Pines
Latitude 35.1685 Longitude.-79.4187 County Moore City: Southern Pines
3. Approximate date land -disturbing activity will commence March 12022
4. Percent Impervious 88.79%
5. Purpose of development (residential, commercial, industrial, institutional, etc.): Commerical
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.6 Acres
7. Amount of fee enclosed: $ 1,350
The application fee of $300.00 per acre plus $150.00 for each additional acre, or part thereof, and is
assessed without a ceiling amount. Any substantial revision to a previously approved, active plan is $50
per acre, or part thereof.
8. Has an erosion and sediment control plan been filed? Yes No Enclosed X
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Woodke E-mail Address dwoodke0=)midlandatlantic.com
Telephone [phone] Cell Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Hyperactive Commercial Investments, LLC
Name Telephone Fax Number
25 Shaw Road
Current Mailing Address Current Street Address
Pinehurst NC 28374
City State Zip City State Zip
11. Deed Book No. 4917 Page No. 528 Provide a copy of the most current deed.
Page 3 of 3 1-6-21 B-81

1. Person(s), Company(ies), or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) !f the company orfirm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Midland Atlantic Properties, David Woodke [e-mail]
Name E-mail Address
8044 Montgomery Road Suite 370 _ SA"V�G l
Current Mailing Address Current Street Address
Cincinnati Ohio 45236 l Q'kv'tf-
City State Zip City State Zip
Telephone [phone] Fax r/ -1 1 z-50 1 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:
Tim Carpenter, LKC Engineering
Name
140 Aqua Shed_Ct
Current Mailing Address
[e-mail]
E-mail Address
same
Current Street Address
Aberdeen NC 28315 same
City State Zip City State Zip
Telephone [phone] 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 Registered Agent
Current Mailing Address
City
Telephone
Page 3 of 3
E-mail Address
Current Street Address
State Zip City State
1-6-21
Fax Number
Zip
B-82

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.
David Woodke
Type or print name
Signature
Director of Construction
Title or Authority
�7ellkl&�,J_
Date
I, G>! " e , a Notary Public of the County of
4hlD
State of Alm! -Cu; ate; hereby certify that ._Az?L1 . 2L-_
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 ay of 204'/
Notary
Seal
X MELONNA RAE RITCHIE•SPAHNI
Notary Public
o State of Ohio My commission expires
My Comm. Expires
ro a May 18, 2026
ti
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED: December 17, 2020
Page 3 of 3 1-6-21 B-83