NCC240466_FRO Submitted_20240226

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town
SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
ClouthernQ� 140 Memorial Park Court
ThembriNorth
Sa, Southern Pines,North Carolina 28387
Internationally Recognized foe Pingram t:*ti'e&ence 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: Andrew and Wendy Bowden Residence
2. Location of land-disturbing activity. County:Moore City or Township:Soujhern Pines
Street Address 112 Haddington Dr. Pinehurst
3. Latitude: 35.2194 Longitude: -79.4240 PIN: 857314344950
4. Percent Impervious: 27.98%
5. Approximate date that land-disturbing activity will commence: 3/1/2024 .
6. Purpose of development(residential,commercial, industrial, institutional,etc.): Residential
7. Total acreage disturbed or uncovered(including offslte borrow and waste areas): .34
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 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 Brian Atkins E-mail Address [e-mail]
Telephone Cell# 910-638-3340 Fax#
10. Landowner(s)of Record (attach accompanied page to list additional owners):
Andrew and Wendy Bowden 207-756-2403
Name Telephone Fax#
52 Wilmot St. #2 52 Wilmot St. #2
Current Mailing Address Current Street Address
Portland ME 04101 Portland ME 04101
City State Zip City State Zip
11. Deed Book No. 5552 Page No. 480 (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):
Southern Elite Custom Builders, Inc [e-mail]
Name E-mail Address
1008 Seven Lakes Dr. Unit 4 PO Box 1200
Current Mailing Address Current Street Address
West End NC 27376 West End NC 27376
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). 1 agree to provide
corrected information should there be any change in the information provided herein.
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-ape or print name Title or Authority
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Signature Date
1, DOA/ `J • &ti ei 1 Sri! , a Notary Public of the County of /4 a. r
State of North Carolina, hereby certify tfiat 2 r : o.v A 14 ;n
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 I t day of re-- r L arj; 20 -
Ds,v IAA�Z ''vS �
David J. Zmiewsky
Notary Public
Moore County, i / Lc;7 4
My Commission Expires
3
Notary
Seal
My commission expires ( /
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes❑ No❑
REVISED:January 9,2020