NCC222312_FRO Submitted_20220623

1687
Tour of
outhern Ines
t Or N,onh Carolina
_}t /� 'ihe Ad Sarah Resat
Inlerhumnalq Re -cognized for Dram Errel mm
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
140 Memorial Park Court
Southern Pines, North Carolina 28387
Telephone: [phone] — Fax: [phone]
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 NIA in the blank.)
Part A.
1. Project Name: to 3 P7Mtteh C;t-
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 103 Pi nehu yst N 2'531u
3. Latitude: 35.16i0H0 Longitude: J '1.L4_L{0'PIN: 05(92I(9OgU0q-t"
4. Percent Impervious: 2 5°/v
5. Approximate date that land -disturbing activity will commence:
6. Purpose of development (residential, commercial, industrial, institutional, etc.): YesiGt eft'f7Gi
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0. f N I qG
8. Amount of fee enclosed: $ (U/A-
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 30,000 sq. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
ey Js
Name T1 CQOy E-mail Address +y),ev( ►Aht7Ide,�fiG,{GYs C0rn
Telephone (010MV- 310 Cell # Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Paul M10)315-4S-03 321q
Name Telephone
I o W"I li mff V, - 1101U DlIve,
Current MailingAddress
NaWv6t NC
City State Zip
11, Deed Book No. h �- ` Page No. NVO
5Awe-
Current Street Address
City
Fax #
State
Zip
(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):
� hicl�e �u,`I'cicfs, c,�c �U o lot 'fudcbitilders .Corn
Name
E- liam Address
F0 OUX 1�501
25­o N_ hne
Current Mailing Address
Current Street Address
500hetm Pihes NL
bmtherh Vihes NL
City State
Zip City State Zip
Telephone (�+o)l�a-3�b�
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 #

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 attomey-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.
ler Ca-OIC Me�.b�
Type or print name Title or Authority
Signature Date
I, � '.CA 0 d �� V C c1- , a Notary Public of the County of •1f q C)0r
State of North Carolina, hereby certify that Tuley Cn1L
appeared personally before me this day and b ng duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal, this1 'day of fir. l 20
�"�pp�
Comm -Aires _ Notary
Seal = o�• A �'
=� 0 "••. Ue t- IGw� My commission expires -- -[ - aL-
``'�� COUt4�
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED: January 9, 2020