NCC215839_FRO Submitted_20211021

°°V�'�'� Gaston County
A Gaston Natural Resources Department
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is4e
G 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
�rtaR$�s Soil Erosion & Sedimentation Control
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Financial ResponsibilitylOwnership
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No person may initiate any land -disturbing activity on one (1) or more acres of property in all portions of
Gaston County, except for that property within the city limits of the incorporated municipalities of Gaston
County who have not adopted the Gaston County Soil Erosion & Sedimentation Control Ordinance, before
this form and an acceptable Soil Erosion & Sedimentation Contro{ Plan have been completed and approved
by the Gaston County Natural Resources Department's staff.
(Please type or print and, if question is not applicable, place NIA in blank)
PART A:
Project Name Tupelo (Bldgs. 1009 — 1012 and 1025- 1029)
2, Location of land -disturbing activity
City Gastonia Highway/Street Glenwood Drive
3. Approximate date land -disturbing activity will commence Oct. 2021
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.2f
6. Amount of fee enclosed $ 1,200.00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
Tupelo Gastonia, LLC
Name
8320 Judy Witt Lane
Mailing Address
Vienna, VA 22182
City State Zip
[phone]
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
9. indicate Deed Book and Page where deed(s) or instruments) are recorded
Deed Book 5179 Page 1717
Deed Book Page
Deed Book Page
10. Tax Map No. Lots not assigned Block Lot No.
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PART 8:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
NVR Inc. (dba Ryan Homes)
Name
13924 Professional Center Dr., Suite 100
Mailing Address
Huntersville, NC 28078
City State Zip
[phone]
Telephone Number
Mike Caldwell
Contact Name for Inspection Reports
mcaldwel a@n vrin c. com
Email Address
[phone]
Telephone Number
N/A
Fax Number
If the Financially Responsible Party is not a resident of Nerth Carolina, give name and street
address of a North Carolina agent.
Corporation Services Company (Registered Agent)
Name
2626 Glenwood Ave., Suite 550 2626 GlenwoodAve., Suite 550
Mailing Address Street Address
Raleigh, NC 27608 [phone]
City State Zip Telephone Number
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.
Corporation Services Company (Registered Agent)
Name
2626 Glenwood Ave., Suite 550 2626 Glenwood Ave., Suite 550
Mailing Address Street Address
Raleigh, NC 27608 [phone]
City State Zip Telephone Number
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 authority to execute instruments for the financially responsible person). 1 agree to provide
corrected information should there be any change in the information provided herein.
Type or int Name Title or Authority
re Date -
I, 1�ohjA(�N- Ga tt ,b a Notary Public of the County of-11ACD�h , State of North
Carolina, hereby certify that _Se4{n (7a4Cr- 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 jib"' day of�tA6ec- , 2 0al .
Notary f SEAL
ANNETTE N GALLUP
Notary Public, North Carolina
Lincoln County
My Commission Expires
February 29, 2024
' 6900 ay
My Commission Expires
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