NCC230128_FRO Submitted_20230118

CwA
uthern roes
Isrs4rry+ixucaih' i�rr7�lw.vi by i�s+}s7,,sn F.u,^t7r�a'c
FINMCIiAL RESPONSIB LITYRYINNiERSHI P FORM
SEDWENTATION POL.LUTHM CONTROL ACT
Pudic Works Deoartrrrent
1+Ni 1111am orial Panic court
Southern Piro, North Carolina 26387
T61e010rte: 910-69219M — Faac 910-692-1085
No Person may irk any land-distuTbing activity 9WW than 30,000 sq. % (wcluding lots or tracts of land that are
a part of a Cmi non Plan of Development that the total disturbance will excaeW 30,000 sq. I) as oovered by the
Town's Code of Ordinances before this farm and an a400ixtable erosion and sedirnentation control plan have been
Completed and approved by the Town of Southern Pines. (Please type or print and, if the ques* n is not applicable
or inforrnat On unmwdlab#e, Piece NIA in the blank.)
Part A.
1. Project Name:
2. Location of land -disturbing activity: County. Moore City or Township: Southern Pines
Street Address
S. Ladwe: 35.2207 Longitude: -79.4315 PiN: 857309150591
4. Percent Impervious: 150%
5. Approximate date that land -disturbing activity will commence: 1119/2023
6. Purpose of development (residential, commercial, industriai, insfitutlonal, etc.): Residential_
7. Total acreage disturbed or uncovered (including of-silie borrrow and wee areas): 29
8. Amount of fee enclosed: S NIA
The application fee is $M.00 for the first acre pkm $150.00 for each additional acre, or pit thereof.
The revised plan rwWgw III is for each subng"i ~ the 2nd raMiiww.
Any substantial revision to a proviousiy approved, active plan is $50 per acre, or part thereof.
Ne Fee fir Myrlor QRMIIMFtYon Acmt less am XON as IL of dl once.
9. Person to oontact should erosion and sediment control issues arise during land -disturbing acWW.
Name Fernando Silva E-mailAddress [e-mail] _
Telephone _ Cell # 910-783-6592 Fax #
10. Landowner(s) of Reid (attach accompanied page to list additional owners):
Fernando Silva
Name
144 North Moore Rd.
Current Mailing Address
Robbins NC 27325
City State
Zip
910-783-6592
Telephone Fax #
144 North Moore Rd.
Cument Street Address
Robbins NC 27325
CRY State ZiP
11, Deed Book No. 5933 Page No. 183 (Pfwfkla 8 COPY of the roost current deed).

Part B.
1. Persorr(s) or firm(s) who is financially responsible for the land -disturbing activity
(Provide a compinhanshm Ist of all mponsWe parties on an attached sheet).
Fernando Rebollar Silva LLC [e-mail]
Name E-mail Address
144 North Moore Rd. 144 North Moore Rd.
Current Mailing Address Cument Street Address
Robbins NC 27325 Robbins NC 27325
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 tine designated North Carolina Agent;
Name of Registered NC Agent
Current Mailing Address
E-mail Address
Current Street Address
City state Zip City state Zip
Telephone Fax #
(b) If the Financially Responsible Pity is a Partnership or other person engaging in business under an
assumed name, arch a copy of the CertlRcaft of Assumed Name. If the Financiafly 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
Cunt 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 attomey4n-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.
ype or print name Title or Authority
U--) 1 2---2,
Signature Da
a Notary P blic Cou nty of
State of North Carolina, hereby certify that nr{1(l(�
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--Lday of 20
'A
I
0
`,`���������A1rr�'`
J �I
9
0 NOTARY z=
SAI PUBLIC
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
Notary
My commission expires j,D
REVISED: January s, 2020