NCC250713_FRO Submitted_20250312

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Town of v SEDIMENTATION POLLUTION CONTROL ACT
OPublic Works Department
outhern Ines 140 Memorial Park Court
4. 14 NoouthRolina Southern Pines, North Carolina 28387
r? � The hlid South Reson
Internationally Recognized for 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.
1. Project Name: 25 Middlebury
2. Location of land-disturbing activity: County: Moore City or Township: Southern Pines
Street Address 25 Middlebury Rd. Pinehurst
3. Latitude: 35.2409 Longitude: -79.4269 PIN: 857400225900
4. Percent Impervious: 22%
5. Approximate date that land-disturbing activity will commence: 3/10/2025
6. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
7. Total acreage disturbed or uncovered (including off-site borrow and waste areas): .63
8. Amount of fee enclosed: $ N/A
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 Ken Bass E-mail Address [e-mail]
Telephone Cell# 910-528-6481 Fax#
10. Landowner(s)of Record(attach accompanied page to list additional owners):
G. W. B. Construction, LLC 910-528-6481
Name Telephone Fax#
215 Palmer Grey Court 215 Palmer Grey Court
Current Mailing Address Current Street Address
Aberdeen NC 28315 Aberdeen NC 28315
City State Zip City State Zip
11. Deed Book No. 6215 Page No. 144 (Provide a copy of the most current deed).

Part B.
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):
G. W. B. Construction LLC Ikbass36ahotmail.com
Name E-mail Address
215 Palmer Grey Court 215 Palmer Grey Court
Current Mailing Address Current Street Address
Aberdeen NC 28315 Aberdeen NC 28315
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
correc ' d info oration should there be any change in the information provided herein.
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Signature
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I, `O `)`�'- C\\- f *' , , a NotaCounty �Public of the of 1 P e'
State of North Carolina/hereby certify that � ;-_e;
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 (4.j day of 1---4.", , 20 (1-r„>-
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FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No []
REVISED:January 9,2020