NCC223996_FRO Submitted_20221202

Town of ;� �V,��cr h Its
OLff ern Ines
- Th
�;�� ,�,� � s\or,n Carolina
/1 e Tsid south resort
Internationally Recognized for ProAram Excelleace
Public Works Department
140 Memorial Park Court Southeni Pincs, NC 28387
Telephone: [phone]Fax: [phone]
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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 c,— S�
2. Location of land -disturbing activity: Highway/Street/Address: 31 i11 A:,,-, 't Rcr.8
Latitude 3513'33.ar) ' Longitude-7 *;WW1 ,.W' County Moore City: SLAVvx
3. Approximate date land -disturbing activity will commence
4. Percent I mpervious 3 /�
.I(v Lv
5. Purpose of development (residential, commercial, industrial, institutional, etc.): �rv►,rr s�.v\
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): } 3 . O a c
7. Amount of fee enclosed: $ '—_7 , t
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 L
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name�—E-mail Address iiS�.� tom
Telephone
Cell
Fax
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
1s— ��P"ArA Drrkyc
Current Mailing Address Current Street Address
06.,-0^gfJe-_ AX— bi K3q?
City State Zip
City State
Zip
11. Deed Book No-5 71r 9 Page No. 3 9 S Provide a copy of the most current deed.
57P.�X kob
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.
ry
Y�14rA t i rla� / 4 L.'A �nw .1' �- C T, SG IMA? 15 (2 Sr�rI o � ''.5 aye_ - CO'n
NameT E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone '4 la' &&" - Fax
State
Zip
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
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax
State Zip
(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:
s
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
fits ace. CC"
CQr /(J(:f aY
City State Zip City State Zip
Telephone u o - �kV '-?S%�q Fax Number
Page 3 of 3 1-6-21 B-82

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.
� e r► ru h n /�ArLso �_P6r�
Type or print name
Signature
Title or Authority
-11) �t I >O.;L- -:-L—
D ate
I, Cl► tC1C ��'10 a Notary Public of the County of MOOR2.
State of North Carolina, hereby certify that 1�1� �[`fl�CY1 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 1"C day of_d -U 2022
v V
JENNIFER WIN{CKLHOFER otary
NOTARY PUBLIC
Moaggeounty
Norz arolina
My Commission Expires April 21, 2026
My commission expires i1AD121 1 6211, a WCO
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED: December 17, 2020
Page 3 of 3 1-6-21 B-83