NCC223778_FRO Submitted_20221108

say
Town of s r
C),
outhern ines
fys ��:`. The Mid Srth Carolina FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Internationally Recognized 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 Waterworks Phase 1
2. Location of land -disturbing activity: Highway/Street/Address: 1605 Central Drive
Latitude 35.21899 Longitude-079.394167 County Moore City: Southern Pines
3. Approximate date land -disturbing activity will commence 7-15-22
4. Percent Impervious 13%
5. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.28
7. Amount of fee enclosed: $ $1,200
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 Kevin Lindsay E-mail Address kevinlindsay(aD_crawforddsn.com
Telephone [phone] Cell 910-920-7661 Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
PTAH LLC 910-639-1985
Name Telephone Fax Number
730 Bennett St same
Current Mailing Address Current Street Address
Southern Pines NC 28387 same
City State Zip City State Zip
11. Deed Book No. 5009 Page No. 508 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.
PTAH LLC [e-mail]
Name E-mail Address
same
Current Mailing Address Current Street Address
Southern Pines NC 28387 same
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
Current Mailing Address
E-mail 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:
Andy Bleggi, Member Manager PTAH LLC [e-mail]
Name of Registered Agent E-mail Address
730 Bennett St Same
Current Mailing Address Current Street Address
Southern Pines NC 28387 Same
City State Zip City
Telephone [phone] Fax Number.
State
FE
Page 3 of 3 1-6-21 B-82

The above information istrue and correct tothe best ofnmyknowledge and belief and was provided bymeunder
oath (This form must be signed by the Financially Responsible Person if an individual or his attorney- in -tact or if
not an individual, by an officer, director, partner, or registered agent with the authority to execute instruments for
the Financially Responsible Person). | agree to provide corrected information should there beany change in the
information provided herein.
Andy. Ble#gi Member, Manager
Type orprint name Title urAuthority
re =— Date
State of North Carolina, hereby certify that A06L, 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 fL-1 4—
�
My commission expires
FOR TOWN USE ONLY:
Covered by5/7OProvis[� Provision: Yes �~ No �[�
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REVISED: Decemberz7, 2020