NCC231624_FRO Submitted_20230531

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town off SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
0outhern Ines 140 Memorial Park Court
j, t ?0 g North Carolina Southern Pines, North Carolina 28387
L`‘ The Mid South Resort
Internationally Recotgnizedfor Program Excellence 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 print and, if the question is not applicable
or information unavailable, place N/A in the blank.)
Part A.
110 Brookfield Drive
1. Project Name:
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address 110 Brookfield Drive,Pinehurst,NC
3. Latitude: 35.222930 Longitude: -79.428120 PIN: 857309261343
4. Percent Impervious: 21
5. Approximate date that land-disturbing activity will commence: 22 May 2023
6. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): .17
8. Amount of fee enclosed: $ 0
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 Warren Dabbs E-mail Address [e-mail]
Telephone Cell#910.279.7703 Fax#
10. Landowner(s)of Record (attach accompanied page to list additional owners):
Paul Ellis 828.545.9002
Name Telephone Fax#
3306 Carmel Road
Current Mailing Address Current Street Address
Charlotte,NC 28226
City State Zip City State Zip
6 511
11. Deed Book No. Page No. (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):
Dabbs Brothers LLC [e-mail]
Name E-mail Address
PO Box 2032 126 Cypress Circle
Current Mailing Address Current Street Address
Wilmington NC 28402 Southern Pines NC 28387
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 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.
Warren Dabbs Contractor
Type 9 print name Title or Authority
4
7 edf .,..,‘...----.-.- gal -... L
Signature Date 1/4/
I, POW C Dabbs , a Notary Public of the County of �eul T`f c�n U Ve l�
State of North Carolina, hereby certify that Wi 1 Q(Y1 \/\Jrxr.e.n �G�bbS j1-
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 1p day of r.C>bV Ia-+il , 20 23
AMANDA C DABBS
NOTARY PUBLIC diudza_New Hanover County
_ North Carolina
My Commission Expires August 10,2027 Notary
Seal
My commission expires ld.5+ I0) 2021
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:January 9,2020