NCC241448_FRO Submitted_20240510

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]
NORTH CAROLINA
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 Kersten residence
2 Location of land-disturbing activity County Moore City or Township Southern Pines
Street Address 139 Brookfield Drive
3 Latitude 35.216562 Longitude. -79.425278 PIN 857314249081
4. Percent Impervious 22.5%
5. Approximate date that land-disturbing activity will commence 05.01 2024
6. Purpose of development(residential commercial, industrial, institutional, etc ) residential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas) .375
8. Amount of fee enclosed- S
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 Lily Camina-Vick E-mail Address [e-mail]
Telephone [phone] Cell# 910.690.2249 Fax# [phone]
10 Landowner(s) of Record (attach accompanied page to list additional owners)
Pete Kersten 703.424.8871
Name Telephone Fax#
9912 Lindel Lane
Current Mailing Address Current Street Address
Vienna VA 22181
City State Zip City State Zip
11 Deed Book No 6063 Page No. 385 (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):
Camina Design & Construction [e-mail]
Name E-mail Address
165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax# [phone]
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:
Jose' Camina [e-mail]
Name of NC Registered Agent E-mail Address
165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax# [phone]

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.
L Cel„,„.,,a_ \(\
T or ,print me Title or Authority
/-1 2 S Z�
Signatu Date
I7U �('4'1 , a Notary Public of the County o
State of North Carolina, hereby certify that LA 1 Q'Ar 1 I I'}rr-— V 1
appeared personally before me this day and be6 duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal, this, h5day of 1 V\ , 20 4
TABATHA S DOZIER
NOTARY PUBLIC �j ��(�I /�
Moore County �j'VV"v" V l�
North Carolina
My Commission Expires 10-24-2026 Notary
Seal �1
My commission expires I U- ?4� v,V
FOR TOWN USE ONLY
Covered by 5/70 Provision: Yes❑ No El
REVISED January 9,2020