NCC241540_FRO Submitted_20240611

,Xre
c he 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). 3 agree to provide
corrected information should there be any change in the information provided herein,
^l'AC N1
\JVAVGE
Type r p int name Title or Authority --
1 )\-/' RL. 51 I� �.� 2-4
Signature Date
e1n (A I� P7 1 i a ota; Pubiic o{the Ce uni of «i
State of North Carolina, hereby certify that H-topci M to S.S
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 S �I day of N a. ; 2O 2A
it'S.3,t1A
M�FG) / 11/1/1-PAr Iv)
BAR'1P j `J Notary
yoh - My commission expires bq-7 5 -7,0 Z
FcovNrf,r1
FOR TOWN USE ONLY:
Covered by 5/70 Proviso.r_ Yes 0 No 0
REVISED;January 9,2020

,i B.
1. Person(s)or firm(s)who is financially responsible for the land-diSturbing activity
(Provide a comprehensive list of ail responsible parties on an attached sheet):
Eastcoast Development Group, LLC ecdg.hopeagmail.com
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
/-)
Tetephoneq l 0 -Z Z' ! 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#

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of ___ SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
C-Iouther:n ines 140 Memorial Park Court
'- North C)1O iOO Southern Pines, North Carolina 28387
f= ec oP ogr sv iz Telephone:[phone]—Fax: [phone]
internationally Recognized for Pra,,ram Excellence
No person may initiate any land-disturbing activity greater than 30,000 sq.ft.(including tots 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 infom ation unavailable,place NA in the blank.)
Part A.
1. Project Nat tie: Chappell
2. Location of{lan sturbing activity: County:Moore City or Township:Southern Pines
Street Address 17 Ridgeland St, Pinehurst
3. Latitude: 35.2327 Longitude: -78.433 PIN: 8573 009
,-e
4: Percent impervious: 17%
5. Approximate date that land isturbing activity will commence: 61112024
6 Purpose of development(residential,commercial,industrial, institutional etc.): Residential
7. Total acreage disturbed or uncovered(including
off-site borrow and waste areas): .25
8: Amount of fee enclosed:$ NIA
The application fee is 5300.00 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 per acre,or part thereof
No Fee for Minor Construction Activities less than 30,tW0 sq.rt.of disturbance.
9: Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name .._NomeMane= E-mmailAddress e g_hf'Pe-@g=??ail_Cnm
Telephone Cell# 910-729-0277 Fax#
v. Landowner(s) of r (attach r aei+es i s ee ei�3 u to list additional Ri rs).
Cameron Chappell 910-986-5964
Name Telephone Fax.#
430 Yadkin Rd 430 Yadkin Rd
Current Mailing Address Current Street Address
Southern Pines NC 28387 Southern Pines NC 28387
City State Zip City State Zip
11. Deed Book No. 5892 Page No. 393 (Provide a copy of the most current deed).