NCC240397_FRO Submitted_20240305

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Southern Public Works Department
140 Memorial Park Court
Pines Southern Pines, North Carolina 28387
Telephone: [phone]— Fax: [phone]
IORTN ( A POI IN!!
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.
6 Ridgoland street
1. Project Name:
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address 6 Ridgeland Street,Pinehurst,NC
3. Latitude: 35.233800 Longitude: -79.429730 PIN: 857400106279
4. Percent Impervious: 27
5. Approximate date that land-disturbing activity will commence: 24 JAN 2024
6. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): .21
8. Amount of fee enclosed: $ 0
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 Warren Dabbs E-mail Address [e-mail]
Telephone Cell # 910.279.7703 Fax#
10. Landowner(s) of Record (attach accompanied page to list additional owners):
David and Stephanie Cox 703.969.7260
Name Telephone Fax#
113 Chanticleer Drive
Current Mailing Address Current Street Address
Pinehurst,NC 28374
City State Zip City State Zip
5553 103
11. Deed Book No. Page No. (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):
Dabbs Brothers LLC [e-mail]
Name E-mail Address
PO Box 2032 126 Cypress Circle
Current Mailing Address Current Street Address
Wilmington NC 28402 Southern Pines NC 28387
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.
gar- W7/441-1 "ifrie7cr
Type or lint name Title or Authority
li4.-1-t., 07/2?
Signature Date
I, A YCL h d k C 1)A4919 s , a Notary Public of the County of Ni2w Har)0 ve r
State of North Carolina, hereby certify that 14,,vie h Co abto S
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. 11
Witness my hand and notarial seal, this 11 day of contA a r y , 20 Z.Li
AMANDA C DABBS
NOTARY PUBLIC arik /� 1( �/� V'
New Hanover County �/l (�(�, J/
North Carolina—
My Commission Expires August 10,2027 Notary
Seal
My commission expires AVti U-S-1- J 0l 202?
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020