NCC233368_FRO Submitted_20231113

tom; FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of -> SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
outhern 140 Memorial Park Court
rfE NVit:taml4�a Southern Pines, North Carolina 28387
rf or P ogr m E4c e ce Telephone: [phone]—Fax: [phone]
fntcrrtationa!!y Recogn;zerf far Program Gc�l:rncc
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: Sassano Residence
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address 218 Meyer Farm Dr. Pinehurst NC. 28374
3. Latitude: 35.2298 Longitude: -79.4143 PIN: 857307683818
•
4. Percent Impervious: 12%
5. Approximate date that land-disturbing activity will commence: 1 1/20/2023
6. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): .22
8. Amount of fee enclosed: $ N/A
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 2"d 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 sq. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Hope Maness E-mail Address [e-mail]
Telephone Cell# 910-729-0277 Fax#
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Jason Grant & Patrick O'Reilly 910-995-2229
Name Telephone Fax#
PO Box 3519 13 B Pinehurst Manor
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
11. Deed Book No. 5430 Page No. 467 (Provide a copy of the most current deed).

art 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):
Eastcoast Development Group, LLC [e-mail]
Name E-mail Address
PO Box 3519 25 Dowd Cr.
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
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:
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.
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Signature Date
I, iVit �e) \ke. A, 0.,00e_ , a Notary Public of the County of 17 k..) i-mot
State of North Carolina, hereby certify that A 0 pt> Vt 0,...0 eS 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 '� day of Neo'1ber , 20 9
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FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020