NCC231028_FRO Submitted_20230414

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of 'i•[°r SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
0; oUther'n 1neS 140 Memorial Park Court
Southern Pines,North Carolina 28387
n Internam*Recognized f Mid South Resort
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: 7-61qROL 1Z..-03
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address LSO HuLL/kJGAR DQtvE
3. Latitude: 3 5. 22.8 9 Longitude —7 9.3800 PIN: 8583 Oo 6$55 70
4. Percent Impervious: 3 a Flo
5. Approximate date that land-disturbing activity will commence: A P R>L Z0 2.3
6. Purpose of development(residential,commercial,industrial, institutional,etc.): REST DE,uT r A L.
7. Total acreage disturbed or uncovered(including off-site borrow and waste areas): O.Z'8
8. Amount of fee enclosed:$
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 Minor Construction Activities less than 30.000 so. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name LDS I.I GRovFS E-mail Address <<st:e•9roveSGlldre•JWCisJets key aes,com
Telephone 91 O-4 8 4-4 84`f Cell# Fax#
10. Landowner(s)of Record(attach accompanied page to list additional owners):
DFC R. voLvER 11-
Name Telephone Fax#
13606 SgwGitl}SSCrgas,13t.lw 5;Srs 2 � SAME
Current Mailing Address Current Street Address
Pont+. VEpRA FL 32682 SA►,E,
City State Zip City State Zip
11. Deed Book No 58 S'f Page No. 3 87 (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):
DREAM rioDC26 NoµE$, LL(. les11e..grove.Seckeo4•nJer5 %0Mes.Co,nm
Name E-mail Address
370, RAEFoRp 120401 5vi'1Tc 241C1 S9Ma
Current Mailing Address Current Street Address
TAVFTTFv,LLE NC 2B309 Snmg
City State Zip City State Zip
Telephone 910- $ 6-H$6 Li 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 Current Street Address
City State Zip City ' State Zip
Telephone Fax#

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.
1.- GSLAG G42.ovEs D►v/isi otJ PRE-61 pewr
Type or print name Title or Authority
Zta8t 0:2,
..gnature Date
I, ra__ L Creer\I a Notary Pubic of the county of YYl
State of North Carolina, hereby certify that . e5I I c C"3OW
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. rn J n
Witness my hand and notarial seal, this .Z day of ✓�l aft,c I , 20 2
o,° ... GR 0000 C
� • F2�OT 4 No ry
Seal
G AvBL C° :�; My commission expires 5_J D_2 +,'''',,<4N. CO\3
,q,,,Nu u„„N,,s,
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes❑ No 0
REVISED:January 9,2020