NCC231561_FRO Submitted_20230524

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Town of +`r
lt•5t. Public Works Department
I HO Memorial Part.Court Southern Pines, NC 28387
Telephone:[phone] F-ax:910-592-1085
(Liouthern Ines
r r�, C The MO NorthR�°'a FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Internationally Recognized for Program Ezrefkmcet
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.
Overlook at Pineridge Apartments
1. Project Name
2. Location of land-disturbing activity: Highway/Street/Address: Pineridge Parkway
35.16900.16900 79.g156
_Longitude County Moore City: Town of Southern Pines
3. Approximate date land-disturbing activity will commence 4/15/23 -Projected
4. Percent Impervious 57%
5. Purpose of development(residential,commercial, industrial,institutional,etc.): Multi-family Residential
6. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 13.05
7. Amount of fee enclosed:$ 2,250
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 "
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Adam Tucker;Spencer Peterson [e-mail] E-mail Address @ dc.com
spencerpeterson@zdc corn
Telephone [phone] Cell 910.800.9231 Fax N.A.
10. Landowner(s)of Record (attach accompanied page to list additional owners):
ZP 378 Southern Pines II, LLC, a North Carolina 910.800.9231 N A.
limited liability company
Name Telephone Fax Number
111 Princess Street
Current Mailing Address Current Street Address
Wilmington NC 28401 "
City State Zip City State Zip
11. Deed Book No. 5934 Page No. 1 Provide a copy of the most current deed.
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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.
ZP 378 Southern Pines II, LLC, a North Carolina adamtucker@zdc corn
limited liability company _ [e-mail]
Name E-mail Address
111 Princess Street
Current Mailing Address Current Street Address
Wilmington NC 28401 „
City State Zip City State 11
Zip
Telephone [phone] Fax N.A.
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 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:
Herbert J. Zimmer [e-mail]
[e-mail]
Name of Registered Agent E-mail Address
111 Princess Street
Current Mailing Address Current Street Address
Wilmington NC 28401
City State
Zip City State Zip
910.800.9231
Telephone Fax Number
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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.
ZP 378 Southern Pines II, LLC, a North Carolina
Jeffrey L. Zimmer limited liability company
By: Jeffrey L. Zimmer, Manager
Type or print name Title or Authority
1/17/23
Signature Date
I, Garr'+ +1411 -f a Notary Public of the County of Nt w 1Q OvLr
State of North Carolina, hereby certify that ' i ff L z+ /'?gv149r4^ 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 th} day of 7ah4cl11 20 2.3
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FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes El No ❑
REVISED:December 17,2020
Page 3 of 3 1-6-21
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