NCC243212_FRO Submitted_20241018

•
Town of .Ci-.of�`%1�H7
riiintoirs Public Works Department
140 Memorial Park Court Southern Pines,NC 28387
Telephone: [phone] Fax:[phone]
(.Douthern Ines
,_.f ,;., The Mid So Northuth Re Carovelinart FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Internationally Pecogyuzed 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 Penick Village Redevelopment Phase 1
2. Location of land-disturbing activity: Highway/Street/Address: 500 East Rhode Island Avenue
Latitude 30.1729° Longitude -79.3823° County Moore City: Southern Pines
3. Approximate date land-disturbing activity willcommence November 2024
4. Percent Impervious 46%
5. Purpose of development (residential, commercial, industrial,institutional,etc.): Residential
6. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11.6 ac
7. Amount of fee enclosed: $ $1,950.00
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-disturbing activity:
Name Tony Bornhorst E-mail Address [e-mail]
Telephone [phone] Cell Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Penick Village Inc. [phone]
Name Telephone Fax Number
500 E Rhode Island Ave 500 E Rhode Island Ave
Current Mailing Address Current Street Address
Southern Pines, NC 28387 Southern Pines, NC 28387
City State Zip City State Zip
11. Deed Book No. 3647 Page No. 291 Provide a copy of the most current deed.
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 may be listed as the financially responsible party.
Penick Village Inc. [e-mail]
Name E-mail Address
500 E Rhode Island Ave 500 E Rhode Island Ave
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:
Alva Cromartie [e-mail]
Name E-mail Address
500 E Rhode Island Ave 500 E Rhode Island Ave
Current Mailing Address Current Street Address
Southern Pines, NC 28387 Southern Pines, NC 28387
City State Zip City State Zip
Telephone [phone] 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 8-82

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.
Alva Cromartie President and Chief Executive Officer
Type or print name Title or Authority
Signature Date
1, �1 AA p
USQ.f'L x L`�/N/S , a Notary Public of the County of All a r °
State of North Carolina, hereby certify that Alva Cromartie 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 . ' day of Oal6b°r , 20 24
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0 COv „„to My commission expires,,
FOR TOWN USE ONLY:
Covered by S/70 Provision: Yes ❑ No ❑
REVISED:December 17,2020
Page 3 of 3 1-6-21 B-83