NCC232770_FRO Submitted_20230914

Town of
O�
outhern uses
#,a 4.. Forth Carolina
The Mid South Resort
Internationally Recognized for dram EKce4ence
Public Works Department
140 Memorial Park Court Southern Pines, NC 28387
Telephone:[phone] Fax:[phone]
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity greater than 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 and the Land Quality Section,
INC. Department of Environmental Quality. (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
Patricks Pointe Apartments
2. Location of land -disturbing activity: Highway/Street/Address: NE Service Rd. (SR2091
Latitude 35.186 Longitude-79.391 County Moore City: Southern Pines
3. Approximate date land -disturbing activity will commence June, 2023
4. Percent Impervious 35%
5. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential (MF)
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 27
7. Amount of fee enclosed: $ 4,200
The application fee of $300.00 per acre plus $150.00 for each additional acre, or part thereof, and is
assessed without a ceiling amount. Any substantial revision to a previously approved, active plan is $50
per acre, or part thereof.
8. Has an erosion and sediment control plan been filed? Yes No x Enclosed
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andrew Mer(cle, PE E-mail Address [e-mail]
Telephone [phone]
Cell 804-240-1911 Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
928 -6Sc}c
Name Telephone Fax Number
2(n_C11 I) 5 A ;h C
Current Mailing Address Current Street Address
FL 33133 5 ry1 -
City State Zip City State Zip
11. Deed Book No. 5816 Page No. 479 Provide a copy of the most current deed.
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Part B.
I. Person(s), Company(ies), or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
VG Pines Residential, L.LC, Logan Burnett *[e-mail]
Name E-mail Address
2601 South Bayshore Dr. 17th Floor SAME
Current Mailing Address Current Street Address
Miami FL 33133 SAME
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:
Business Filings Incorporated [e-mail]
Name E-mail Address
160 Mine Lake, Suite 200 SAME
Current Mailing Address Current Street Address
Raleigh NC27615 SAME
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:
Business Filings Incorporated [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake, Suite 200 same
Current Mailing Address Current.Street Address
Raleigh NC 27615 same
City
Telephone
State
NA
Zip City
Fax Number.
State
Zip
Page 3 of 3 1-6-21 B-82

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.
Logan Burnett
Type or print name
Signature
Vice -President
Title or Authority
Date
a Notary Public of the County of W%&M1 —
�-londa
State of "'---ice ,-aF9li _ hereby certify that _ appeared
personally before me this day and being duly sworn acknow edged that the above form was executed by him.
Witness my hand and notarial seal, this__A�L_day of VY\ i 20 23
1��N O/V'A)X
Notary
Seal
t e: NADYADAV{S My commission expires AvOuSk 13, U23
S.'A4W13,,2=
!f w. BorNod lha NOWY N* UndambIll
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED: December 17, 2020
Page 3 of 3 1-6-21 B-83