NCC233429_FRO Submitted_20231117

1
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of .13 = i SEDIMENTATION POLLUTION CONTROL ACT
}� Public Works Department
ou ►ern des 140 Memorial Park Court
f. The SW' f� Southern Pines, North Carolina 28387
1Nf711 a°�'►h'mg^z 1 l,rotr rn Excellenre 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.
1. Project Name: Trautman Residence
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address 13 Monteith Place
3. Latitude: _35.229226 Longitude: _79.411602 PIN: _857307780577
4. Percent Impervious: 17.0%
5. Approximate date that land-disturbing activity will commence: 12.04.2023
6. Purpose of development(residential, commercial, industrial, institutional, etc.): residential
7. Total acreage disturbed or uncovered(including off-site borrow and waste areas): .3 acres
8. Amount of fee enclosed: $
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 so.ft.of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lily Camina-Vick Email Address lilvc caminadesign corn
Telephone [phone] Cell# 910.690.2249 Fax# [phone]
10. Landowner(s)of Record(attach accompanied page to list additional owners):
Joan Trautman 740 404 9120
Name Telephone Fax#
358 Bryn Du Drive
Current Mailing Address Current Street Address
Granville Ohio 43023
City State Zip City State Zip
11. Deed Book No. 5884 Page No. 41 (Provide a copy of the most current deed).
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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 hly(acamrnadesign corn
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 camina-iosenc rr corn
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.
L: C 5 M (\L- v ,c�\L kre 'V(Jy'.l �1
Type or print name Title or Authority 2f
()‘,( e _ ki ►1 . 1 . 2v2�
SignICAre Date
I. ik,.:c N- C1 err is; cz , a Notary Public of the County of ADO C e
State of North Carolina, hereby certify that L; L r,AZA.;et. v. — ; t'c
appeared personally before me this day and beingY (cduly sworn acknowledged that the above form
was executed by him. ,,�1�
—
Witness my hand and notarial seal, this /�7' day of AIDVe &\3 r 20 023
i 9 ,,, ,. ,,/_,7,,,,z.,_
-,-,.,\.,, Al, A €,,) rc(
A N.
,`1\- «.,,,•7k, ��ii Notary
Seal NOt^ 9% /
FE O A 9�• -= My commission expires ,j/p�9/per,s"—
FOR TOWN USE ONLY
Covered by 5/70 Provision Yes❑ No❑
REVISED January 9.2020
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