NCC241822_FRO Submitted_20240703

ea 188i
Town of .�cr ? Public Works Department
140 Memorial Park Court Southern Pines,NC 28387
Telephone: [phone] Fax:[phone]
Couthern Ines
!� , r:1 The Mid NorthSouth CarolinaResort FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Internationally Recognized for Program Excellence SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity greater than 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 and the Land Quality Section,
NC. Department of Environmental Quality. (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 Townhomes, 730 S. Bennett St.
2. Location of land-disturbing activity: Highway/Street/Address: 730 S. Bennett St.
Latitude 35.170340 N Longitude 079.401975 W County Moore City: Southern Pines
3. Approximate date land-disturbing activity will commence 4-1-24
4. Percent Impervious 66%
5. Purpose of development(residential,commercial, industrial,institutional,etc.): Residential
6. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1
7. Amount of fee enclosed:$ $300
The application fee of$300.00 per acre plus$150.00 for each additional acre, or part thereof, and is
assessed without a ceiling amount. Any substantial revision to a previously approved,active plan is$50
per acre,or part thereof.
8. Has an erosion and sediment control plan been filed? Yes No Enclosed X
9. Person to contact should erosion and sediment control issues arise during land-disturbingactivity:
Name Kevin Lindsay E-mail Address kevinlindsayi crawforddsn.com
Telephone [phone] Cell 910-920-7661 Fax
10. Landowner(s)of Record (attach accompanied page to list additional owners):
Grosvenor Land, LLC (910)-688-7361
Name Telephone Fax Number
540 SW Broad St. 540 SW Broad St.
Current Mailing Address Current Street Address
Southern Pines, NC 28387 Southern Pines, NC 28387
City State Zip City State Zip
11. Deed Book No. 5504 Page No. 406 Provide a copy of the most current deed.
Note: Property is currently owned by PTAH LLC. It is being subdivided and a portion sold to
Grosvenor LLC who will be building Townhomes and making other improvements. Please see
Attached letter from PTAH LLC authorizing the work by Grosvenor Land, Inc.
Page 3 of 3 1-6-21 B-81

Part B.
1. Person(s), Company(ies), or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole
proprietorship the name of the owner or manager maybe listed as the financially responsible party.
Grosvenor Land, LLC [e-mail]
Name E-mail Address
540 SW Broad St. 540 SW Broad St.
Current Mailing Address Current Street Address
Southern Pines, NC 28387 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 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 Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
Page 3 of 3 1-6-21 B-82

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.
Colin Webster Manager
Type or print name Title or Authority
Signature Date
I, .67- d74��e-f/€111 ,a Notary Public of the County of /L 94,e—�
State of North Carolina, hereby certify that 67O�yit.) 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 42 day of_ (llit/F , 20
Notary
G LEDFS
14
My commission expires
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:December 17,2020
Page 3 of 3 1-6-21 B-83