NCC222467_FRO Submitted_20220725

Town of ire 1887
outhern T�Ws
North Carolina
h The Mid South Resort
Internationally Recognized for Program 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-
I . Project Name: Michael and Alyssa Noone Residence
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 118 Chesterfield Dr. Pinehurst
3. Latitude: 35.2180 Longitude:-79.4191 PIN: 857314448526
4. Percent Impervious: 28.9
5. Approximate date that land -disturbing activity will commence: 7-8-2022
6. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): .29
8. Amount of fee enclosed: $ N/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 sa. ft. of disturbance.
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ken Bass E-mail Address Ikbass36P_hotmail.com
Telephone Cell # 910-528-6481 Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Michael and Alyssa Noone 973-768-9724
Name Telephone Fax #
5209 Bentpine Cove Rd. Same
Current Mailing Address Current Street Address
Jacksonville FL 32224
City State Zip City State Zip
11. Deed Book No. 5698 Page No. 423 (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):
GWB Construction, LLC [e-mail]
Name
27 Chestertown Dr.
E-mail Address
27 Chestertown Dr.
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
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 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 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.
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Signature
Date
1, -, aTNotary Public of the C ty o
Sta a of orth Carolina, h by certif hat
appeared personally before me this ay an being duly sworn acknowledged that the above form
was executed by him. / �
Witness my hand and notarial seal, this�day of N 20 2 Z
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FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
Notary
My commission expi
REVISED: January 9, 2020