NCC223175_FRO Submitted_20221011

Town of ° 1987
uthern Ines0,9 c ' 9 i' Nonh Gvnlm
'the hbd South Rewri
InterTw oruilly Recogn zed 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 pant and, if the question is not applicable
or information unavailable, place NIA in the blank.)
Part A.
1. Project Name: Q er S p n
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address 5o IQid eland 6treet Pikle1 L4V-6f I NG 29,314
3. Latitude: 35, Z3318 Longitude: ­ 49.4 iO4 q PIN: $5(040080L1?bQ
4. Percent Impervious: 23 X.
5. Approximate date that land -disturbing activity will commence: Opt o1 20 yZ
6. Purpose of development (residential, commercial, industrial, institutional, etc.): resiclevi ict I SFH
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
0.195"
8. Amount of fee enclosed: $ W
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:
Name TWn- 0001C
Telephone (°I (0) (V I O - 311(o
E-mail Address t r� 10t1 fiUciGbu i Id e-rS . com
Cell #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
ohn Qi T✓gCCU ae4j5f)
Name
Lazo FgA-oiapel Aol.
Current Mailing Address
F ( r10 x VA- 220 30
City State Zip
Telephone
Current Street Address
City
Fax #
Fax #
State Zip
11. Deed Book No. 555-4- Page No. 57'1' 601 (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,at-if-WdC 6LL+rc1e,V5 t,LC, -imIcr(wjahfUdebwrldens.com
Name E- ail Address
PC t3ox 13o I ZSON• 13ehvlfitt-St•
Current Mailing Address Current Street Address
So nCS N L 28 3 S 9 Sows pj . rq Vp V cs PC _Z
City State Zip City State Zip
Telephone (1 l0) b cl o -'��I (v `I 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.
vier C�k '?l,r��r
Type or print name Title or Authority
r
Signature Date
I, ©hc a a Notary Public of the County of 7-Y?oor2
State of North Carolina, hereby certify that T 000 k
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. I ,
Witness my hand and notarial seal, this 4 /�' day of �"r � � 20 as
41
Tonya L Thomas
Notary Public
Moore County, North Carotins
My Comm. Expires Set 1 2025
Seal
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑
No ❑
Notary
My commission expires
R -1-alas
REVISED: January 9, 2020