NCC242430_FRO Submitted_20240812

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 1 acre(including lots or tracts of land that are a part
of a Common Plan of Development that the total disturbance will exceed 1 acre)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: �0 w i c ke r Sh ci n1 C-t W
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address '0 WtGker Shgrn Ct W PIInelnUrsiiNC 1$314
3. Latitude: 3 • 23 O 8 Longitude: — 11 •4 2 5 3 3 PIN: e 9 y 0021 q y 17-
4. Percent Impervious: 4 3 *1•
5. Approximate date that land-disturbing activity will commence: 0 S'I 1 3 2 0 2 U
6. Purpose of development(residential, commercial, industrial, institutional, etc.): re5 Id en tla I
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0 • t
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 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 1 acre of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ty l e r Coo I - E-mail Address ty le re latifucle bu i iders.corm
Telephone ( 1 I o) bc1 0 - 3101 Cell# Fax#
10. Landowner(s)of Record (attach accompanied page to list additional owners):
13rcicl ley Maria Broussard (q lo ) 5Q1-1- y 536
Name Telephone Fax#
204 Holly Springs Court
Current Mailing Address Current Street Address
Southern Pines Nc 2l3381
City State Zip City State Zip
11. Deed Book No. 13 Page No. 39 2"39 Li (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):
I_cititucle Builders LLc. t. ievC loltii-uclebu iic erc .co m
Name E-mail Address
Po Box t01 I3Z NW Brood Street , suite C
Current Mailing Address Current Street Address
Southern Pipes NC 2e3Q€ Southern Pipes No 22381
City State Zip City State Zip
Telephone (9 l 0)bc10- b1 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#

le above information is true and correct to the best of my knowledge and belief and was provided
oy 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.
y '( Cv k 11\el— 1-1r
Type or print name Title or Authority
9/9/23
Signature Date
I, Kb-lit 4.4) 5-KIR_4.17t .-S ? a Notary Public of the County of 4-(009—P
State of North Carolina, hereby certify that T c G:aok-
appeared personally before me this day and bg duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal, this I.ct 1-day of
Notary
eal Iv1aria-Pia Stratta-Bennett
Moore County,North Carolina Notary Public My commission expires 08 ' O�• ZOZ
Commission No.19992100105
My Commission Expires 8/4/2024
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020