NCC232756_FRO Submitted_20230913

ed1887 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of ha_ SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
0outhern ines 140 Memorial Park Court
r,$,i +, North Carolina Southern Pines, North Carolina 28387
IA The Mid South Resort
Internationally Recognized for 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: MORGANTON PARK NORTH APARTMENTS
2. Location of land-disturbing activity: County: Moore City or Townshiputhern Pine
Street Address 1202 West Morganton Road
3. Latitude: 35.177 Longitude: -79.422 PIN: 20190270,20150046
4. Percent Impervious: 34.47%
5. Approximate date that land-disturbing activity will commence: September 2023
6. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19.69
8. Amount of fee enclosed: $ 3,150.00
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 Hyatt Field E-mail Address [e-mail] cc:[e-mail]
Telephone [phone] Cell#540-273-9626 Fax# N/A
10. Landowner(s) of Record (attach accompanied page to list additional owners):
PACN Realty, LLC(Lot 1)/Morganton Park Realty, LLC(Lot 2A) 910-21 5-2646
Name Telephone Fax#
205 Page Road/5 First Village Drive same
Current Mailing Address Current Street Address
Pinehurst NC 28374 same
City State Zip City State Zip
11. Deed Book No. 5210/5802 Page No. 269/414 (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):
CHIC-MORGANTON PARK NORTH,LLC [e-mail]
Name Contact:Charles Persons E-mail Address
2000 Aerial Center Parkway,Suite 110 1341 Horton Circle
Current Mailing Address Current Street Address
Morrisville NC 27560 Arlington TX 76011
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:
CT CORPORATION SYSTEM [e-mail] cc:[e-mail]
Name of Registered NC Agent E-mail Address
160 Mine Lake Court,Suite 200 160 Mine Lake Court,Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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.
DHIC-MORGANTON PARK NORTH,LLC,a Delaware limited liability company
By:DHI COM,)JNITIES II,LLC,a De aware limited liability company,its sole member
�� )rity
harles F.Persons,Vice President © /05 I 2-023
Signature Date
I, ) (),(t - CU(f\ \\ , a Notary Public of the County of JUi11.If\sA-0 n
State of North Carolina, hereby certify that Chcol-e Persons
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 S}�day of Stp kt,w b— , 20 3
JAMIE CORNWELL
Notary Public, North Carolina
Johnston County
My Commission Expires
June 14,2027
N ary
Seal My commission expires June 19,
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020