NCC232092_FRO Submitted_20230717

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of •% ` SEDIMENTATION POLLUTION CONTROL ACT
Cl4(, Public Works Department
outhern Ines 140 Memorial Park Court
,;�• �' .,tid s'OnhCth4j W4 Southern Pines, North Carolina 28387
t IL„ut
Inrtneibnalb Recognized f«Program Excellence 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. CORNER LOT- At ) IOw4 Pivi ,N $uoc4 R-16
2 Location of land-disturbing activity County Moore City or Township: Southern Pines
Street Address W I0'1-Qr4) /avE S PrwLs C Z8387
3. Latitude: 35 , I a 2$ Longitude — 79• yI Z '-f PIN 8572 196 17‘,3
4 Percent Impervious: 19 Vo
5. Approximate date that land-disturbing activity will commence: APRs t, 2023
6. Purpose of development(residential, commercial, industrial, institutional, etc.): R..ESI DCN1 JAL
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 0. S I{
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 2n° review.
Any substantial revision to a previously approved, active plan is $50 per acre, or part thereof.
No Fee for Minor Construction Activities less than 30,000 so. ft. of disturbance.
9. Person to contact shouldl' erosion and sediment control issues arise during land-disturbing activity.
Name J v5T i r,3 C��R R'5 E-mail Address SuPER1414or,E.$oFTHES90011iu.5 e&wilt.,Cam
Teephone 91 O ' 4 )3 - 0600 Cell# Fax#
10. Landowner(s) of Record (attach accompanied page to list additional owners):
St L.vERSPRIucr,S 1404PIu45 j 1,L.C.
Name Telephone Fax#
Po 4Z. oX `19S1 2.10 MCCASKILL ROAD EAST' $ ►X13
Current Mailing Address Current Street Address
PLLIENuRST NC Z$3-r Pt ►- +wesr Nc Ze37Lf
City State Zip City State Zip
11 Deed Book No 'S�O Page No 326 (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)
SuPFRIO/, ''\0--+6r,5 OF MC_ J�NONU-LS` LlC SuPERtoti;tonE.socTtlE7gaJHi4-(SC GMA�c..Cor�
Name E-mail Address
12.0 ficKeNrziG.5 MILL_ RCiy Ar,E
Current Mailing Address Current Street Address
'v./esr END N C 27376 sF,ME
City State Zip City State Zip
Telephone 71 L' 6 1 3 - f-')60o 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.
•JV.Siiti Hf3kR1::) RES1'005)13LE PE25o►0
Type or print name Title or Authority
Si ,"...., 1-t.,-- 5/672
ature Date
I (S I We�Cf \rN3711A-1---(-1----(--
StateNot Public,o the Countyof 1 tt-- °K-�
of Nortrk Caoolina, hereby'teertify that ,% {J 1►'1 t
appeared perorrally before me this day and being duly sworn acknowledged that the above form
was executed by him. 3
Witness my hand and notarial seal, this i ` day of Ti
• Stacey Staufer
Notary Public (.
Moore Coun �� jirie - _North Carotin
rm Commission Ex iree.
Notary C
Seal / n �,1
My commission expires W
FOR TOWN USE ONLY
Covered by 5/70 Provision Yes E No ❑
REVISED. January 9 2020