NCC230856_FRO Submitted_20230328

Town of r-7
'puther n Ines
honh ('dtoli,a
The AW South Resort
hheernwion* Re *umd for PmjLmm Fxoewhoe
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 N/A in the blank.)
Part A.
1. Project Name: G 4 �- 2- VA
2. Location of land -disturbing activity: County: Moore City or Township: Southem Pines
Street Address ?�- 30 u L t-10 "IL R2 VE. C AQ.TN A r &- PQ L z 3 2
3. Latitude: 35.22 R b Longitude: ^ t4.3-78-3 PIN: $58340�S l`fa
4. Percent Impervious- 2 S e 0
5. Approximate date that land -disturbing activity will commence:
6. Purpose of development (residential, commercial, industrial, institutional, etc.): E= h E►-+ { a L,
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): Q `i 1 A L
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 Mirror Construction activities less than 30 0 o sq. ft, of disturbance.
9. Person to contact should erosion and sediment control issues ariseduringland-disturbing activity:
Name L.I E McV155 E-mail Address
iC E. r a U �5 c�feox ifia �lonres,cew�
Telephone 9 16 -ci D 4 ` qaLLt Cell # Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
LLC
Name
130016 S A Ld G R A 065 Ste z
Current Mailing Address
City State Zip
Telephone Fax #
,S A KP
Current Street Address
City State
Zip
11. Deed Book No. 5� Page No. 387 (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): r
1 �cFlr� 'Fov 5 o+�E LL C i e 1 s clfeo. - ', An C v4
Name E-mail Addr ss
3769 R46FC9�j � z= SAnP-
Current Mailing Address Current Street Address
F- eMVt+"4_, W G. Z830 5AMr--
City State Zip City State Zip
Telephone 9 16 — Lic — 4 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:
Name of NC Registered Agent E-mail Address
Current Mailing Address
City State Zip
Current Street Address
City
Telephone 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.
L,___�
'y a�or print name
re
Title or Authority
3@54Q-5
Date
a Notary Public of the C_ ounty of «1 A
�6
State of North Carolina, hereby certify that �--�' ; , �L
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 �' l 0AIL,'� , 20
pTAlgy Nota
deal = —�D—
nG'. AVBOG : 2 - - My commission expires
R,,""',AND GO ,+•+'+
FOR TOWN USE ONLY:
Covered by 5I70 Provision. Yes ❑ No ❑
REVISED: January 9, 2020