NCC231481_FRO Submitted_20230516

-, ; FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of •}i SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
outhern llles 140 Memorial Park Court
The MN
`Janh Southern Pines, North Carolina 28387
/► south Pe on
Internat;onaiy Recogniaid for Program Excekwe 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. 11
1. Project Name: L C Al2OL 12 -007
2 Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address I75 MuLLiNGr4R Dib LIE, CA12.71N#i,t , N C Z83Z7
3 .Latitude: 3S. 22-9I Longitude -79.3795 PIN: 8Se3Oa688S09
4 Percent Impervious Z L Q'o
5 Approximate date that land-disturbing activity will commence. t"1 AY 2.0 2.3
6 Purpose of development(residential, commercial, industrial, institutional, etc.): RESIDE WTI AL
7 Total acreage disturbed or uncovered (including off-site borrow and waste areas) 0.36 aC
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 sa- ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name LESLi.G.. ROVES E-mail Address LcStie.9rovypdfibiM{',ndcrslwies,c&
Telephone 9 f 0- 4 8 C-4 e6 I Cell# Fax#
10 Landowner(s)of Record (attach accompanied page to list additional owners):
DFC REvoLvEk LLC
Name / Telephone Fax#
JAW 5,ciwGRA45 LIe LE1 L3 DG Sr 51"6 Zu
Current Mailing Address Current Street Address
Po,1E VVDRA FL 32082. Silt-iE
City State Zip City State Zp
11. Deed Book No. 58 S`i Page No 387 (Provide a copy of the most current deed)

Part B.
' 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).
DaEtcirti FIt.IDee,5 ton 5 L LC lest;e•5roves@dream-PWe13643rees. Corn
Name E-mail Address
3709 2aLl=oaa Ron, 5uiTE Zoo Sra�►E
Current Mailing Address Current Street Address
I'AyE1TEVILLE 14C Z8304 5fa(me -
City State Zip City State Zip
Telephone 9t0 —u{9 61-1 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.
LESL1E G72oV13 DIvisin+-) F2E$ID•GOT'
Ty e or print name Title or Authority
).a5
ignature Date
I, arna_ra, L C!(fie a Notary Public of the County of___________d
State of North Carolina, hereby certify that L es I i e C Cave S
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. A
Witness my hand and notarial seal, this 3 day of L kA-C i , 20
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FOR TOWN USE ONLY:
Covered by 5/70 Provision Yes ❑ No ❑
REVISED:January 9,2020