NCC222363_FRO Submitted_20220628

Town of � ¢d 38i2Tt p
pf,
0 outern ines
} forth Carolina
J3"f The Mid .South Reticrrt
Interroumially Recognized for Progmm Excellence
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 N/A in the blank.)
Part A. /� �q/
1. Project Name: 'Br a cl W ►vl � ArA_uk a f A_� L l lk S ie L-t 60. l A B kAw k
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 40 k- l V1 0 -, A
3. Latitude: 35 - i�°F)-T Longitude: Jq. 3� 0_1% 0 PIN:
4. Percent Impervious: a�
5. Approximate date that land -disturbing activity will commence: I
6. Purpose of development (residential, commercial, industrial, institutional, etc.): b►'Y11'1`m Ctgt t VYI l"�i'i4
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
8. Amount of fee enclosed: $ 01 e, ( Gr 6 cAkp"A)l
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.
Person to contact should �e`rosion and sediment control issues arise during land -disturbing activity:
VA L E� A Hc�_JitY E-mail Address
Telephone � 10 "�V Q � 90 Cell # Fax #
10. Landowner(s)ii of Record (attach accompanied page to list additional owners):
fa a.t►°tI,iuII 6V1 0
Name D?A Telephone Fax#
✓� 0.
7C � � � � (A 9 L"J 6CA
Current Mailing9kc1dress Current Street Addr9ss
City State Zip City State Zip
11. Deed Book No_ Page No. V I - a 1 (Provide a cop of the most current deed}.
5 11. Deed Book No4�3 C 5 PDtAAW
5

Part B.
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):
l ' I&A I o . s car
Name E-mail ddre
Current Mailing dress Current Street Adds
City State j R Zip City State Zip
Telephone � cl t �i S Fax #
(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
It,
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:
O-e-S5tC�a [,j `_
V1 less k&tkV1C')Wk61U4 , com
Name of NC Registered Agent E- ail Addr
220q CA C�,c_, oC).
Current Mailing Address
CpALA,3 a M C a 5- 3 2_(D
City �State Zip
y
Telephone l� o 19VO 61? 6 S
30q d
Current Street Address
6a t PLC a& 3,
City State Zip
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 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
c-orrrrected information should there be any change in the information provided herein.
Type or print name t
Yp P Title or Authority
Sig ure Date
a Notary Public of the Co my of Lt
State of North Carolina, hereby certify that _ OLo Y'l G
appeared personally before me this day and being duly sworn acknowledged thafAhe above form
was executed by him.
Witness my hand and notarial seal, this Z..2 day of JUVV , 20 2--
KAREN A TAYLOR
Notary Public, North Carolina
Moore County
My§g Ac9mission Expires
pril21, 2026
FOR TOWN USE ONLY:
Covered by 5170 Provision: Yes ❑ No ❑
Vk-,, _
Notary
My commission expires -(
REVISED: January 9, 2020