NCC241189_FRO Submitted_20240502

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of ' SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
C.Aouthern ll1QS 140 Memorial Park Court
NorthCerolina Southern Pines, North Carolina 28387
Internationally Recognized forrPProogramExcetl� 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: EROSION CONTROL PLAN MID SOUTH END
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address Plantation Dr (PRIVATE)
3. Latitude: 35.184673 Longitude: -79.412247 PIN: 857200626296 (lot 24)
4. Percent Impervious: 23%
5. Approximate date that land-disturbing activity will commence: ASAP
6. Purpose of development(residential, commercial, industrial, institutional, etc.): Resisdential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.98
8. Amount of fee enclosed: $ 600.00
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 sq. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ed Rain E-mail Address [e-mail]
Telephone [phone] Cell# 919-669-4514 Fax#
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Mckee Homes, LLC 910-475-7100
Name Telephone Fax#
4208 Six Forks Rd STE810 4208 Six Forks Rd STE810
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City State Zip City State Zip
11 Deed Book No. 6086 Page No. 131 (Provide a copy of the most current deed).
6086 196
6086 165

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):
Mckee Homes, LLC [e-mail]
Name E-mail Address
4208 Six Forks Rd STE810 4208 Six Forks Rd STE810
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
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:
Ed Rain [e-mail]
Name of NC Registered Agent E-mail Address
4208 Six Forks Rd STE810 4208 Six Forks Rd STE810
Current Mailing Address Current Street Address
Raleigh, NC 27609 Raleigh, NC 27609
City State Zip City State Zip
Telephone [phone] 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.
Type or print name Title or Authority
Signature Date
I, �u SSarin _2e-f/ , a Notary Public of the County of A
State of North Carolina, hereby certify that R-a. i h
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. i�, �/
Witness my hand and notarial seal, this 5T/ day of MG«Gh _, 20 0'
At� 11 �- wt
C�'.: 7i 1"YOB V� ' 7
�Iignd ° Notary
rz: cs? - My commission expires /b 'b e— ef
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020