NCC223913_FRO Submitted_20221122

—'U FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Tmnd _. SEDIMENTATION POLLUTION CONTROL ACT
�uli I n l 1 Public Works Department
140 Memorial Park Court
['.hG,wd Southern Pines, North Carolina 28387
u., —I� ta9,eakri t
, "u;* �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.
1. Project Name Lo Residence
2. Location of land -disturbing activity: County: Moore
Street Address 434 Fort Bragg Road
3. Latitude: 35.148452 Longitude: -79,353219
4
5
6
7
8
D1
Percent Impervious: 7.2%
City or Township: Southern Pines
PIN. 859001494028
Approximate date that land -disturbing activity will commence: 11.16.2022
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas) }
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 2n° 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.
Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Lily Camina-Vick E-mail Address [e-mail]
Telephone [phone] Cell # 910.690.2249 Fax # [phone]
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Joanne Lo 510.345.8867
Name
105 Cliff Court
Current Mailing Address
Southern Pines, NC 28387
City State
11. Deed Book No. 5724
Telephone
Current Street Address
Zip City
Page No. 358
Fax #
State Zip
(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 ail responsible parties on an attached sheet)
Lamina Design & Construction [e-mail]
Name E-mail Address
165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst, NC 28374
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:
Jose' Carnina [e-mail]
Name of NC Registered Agent E-mail Address
165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst, NC 28374
City State Zip City State Zip
Telephone [phone] Fax # [phone]

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.
Lily Camina-Vick
Type or print name
Signature
VP of Design
Title or Authority
11.01.2022
Date
a Notary Public of the County of Mon aY%(\
State of North Carolina, hereby certify that Lti "a ti1� nx V
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 �day of r , 20- =
FOR TOWN USE ONLY
Covered by 5170 Provision: Yes ❑ No ❑
Sac
�
Not /
My commission expires J l
REVISED: January 9. 2020