NCC220305_FRO Submitted_20220126

Gaston County
Gaston Natural Resources Department
a 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
84
Soil Erosion & Sedimentation Control
Financial Responsibility/Ownership
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 Control 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 N/A in blank)
PART A:
1. Project Name Davis Hills
2. Location of land -disturbing activity
City Dallas . Highway/Street Dallas Stanley Hwy
3. Approximate date land -disturbing activity will commence November 2021
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 28 Ac
6 Amount of fee enclosed $ 8,400
7. Soil Erosion & Sedimentation Plan Filed? Yes x No
8. Landowner(s) of Record (Use blank page to list additional owners)
Dependable Development Inc.
Name Name
2627 Brekonridge Centre Drive Suite 104
Mailing Address Mailing Address
Monroe NC 28110
City State Zip City State Zip
704-779-4126
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 5197 _ Page 0005
Deed Book_ __ Page _ _ .
10. Tax Map No. 304841 _ Block Lot No
Page I

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Dependable Development, Inc
Name
2649 Brekonridge Centre Drive
Mailing Address
Monroe NC 28110
Name
Mailing Address
City State Zip City
704-779-4126
State Zip
Telephone Number — Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
S!NMIA ^ VG.J'1F"I/II
Name
Mailing Address Street Address
'
/"1a.,,0e /tot- LtyIIb �oy_7��j-uJl�(a
City State Zip Telephone Number
3. 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 Part is a Corporation give name and street address of the Registered Agent.
Name
Mailing Address Street Address
City State Zip Telephone Number
4. 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). I
agree to provide corrected information should there be any change in the information provided
herein.
-- - --- --- Shaun-Gasparini - Market Partner- -
Type or Print Name Title or Authority
_AA 4'�-
Signature Date
I, _ _-_, a Notary Public of the County of , State of North
Carolina, hereby certify that _ _ _ 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 day of. 2
Notary SEAL My Commission Expires
File: Financial Responsibility -Ownership Form mw
Page 2