NCC232043_FRO Submitted_20230705

„�,; FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Torn„I *'�y n�'° SEDIMENTATION POLLUTION CONTROL ACT
Qouthern ll1eS Public Works Department
140 Memorial Park Court
.t ^,: 'iN.nhhURme it Southern Pines, North Carolina 28387
Inicnwmill IL Ti,,,Nil Sn ,..h
' "rn��alnl''°e,a^t* �,. Telephone• 910-692-1983— Fax' 910-692-1085
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.
1. Project Name Sanders-McGrath Residence
2. Location of land-disturbing activity County Moore City or Township- Southern Pines
Street Address 150 Chesterfield Drive, Pinehurst
3 Latitude 35.214768 79.424437
Longitude PIN 857314331354
4. Percent Impervious 16%
5. Approximate date that land-disturbing activity will commence. 7/12/2023
6. Purpose of development(residential, commercial, industrial, institutional, etc) residential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas) .66 acres
8. Amount of fee enclosed. S
The application fee is$300.00 for the first acre plus 5150.00 for each additional acre, or part thereof
The revised plan review fee is 550 for each submittal after the 2"d review.
Any substantial revision to a previously approved,active plan is 550 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
1 Name Lily Camina-Vick lil E-mail Address [e-mail]
Telephone [phone] Cell# 910.690.2249 Fax# [phone]
10. Landowner(s)of Record(attach accompanied page to list additional owners)
Bailey Sanders 650.815.6615
Name Telephone Fax#
169 Page Road 169 Page Road
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
11. Deed Book No 5661 Page No. 295 (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)
Camina Design & Construction [e-mail]
Name E-mail Address
165 Fox Hollow Court 165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax# [phone]
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.
Jose' Camina [e-mail]
Name of NC Registered Agent E-mail Address
165 Fox Hollow Court 165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State
Zip
Telephone [phone] Fax# [phone]

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.
Type or print name Title or Authority
.Q-A--:— U: (0. 23.�
Ignatu� ��
Date
I,• GM KLLL-_% , a Notary Public of the County of Moor2-t
State of North Carolina, hereby certify that L\LIA Carrh\,v!4 -J,c_vc
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 a 3 day of Jo , 20 a 3
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eve V Z ��/
Sell—rri z �v 2� Notary
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My commission expires t 1- Z3 -Z.oay
III
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes El No 0
REVISED January 9,2020