NCC232523_FRO Submitted_20230823

Gaston County
Gaston Natural Resources Department
a'.. 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
*;:tajuh 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 Fairhaven Place
2. Location of land-disturbing activity
City Gastonia Highway/Street East Hudson Blvd
3. Approximate date land-disturbing activity will commence October 1, 2022
4. Purpose of development(residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 12.82 acres
6. Amount of fee enclosed $ 3,900
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s)of Record (Use blank page to list additional owners)
S Gastonia Church of God, INC
Name Name
310 Carolina Ave
Mailing Address Mailing Address
Gastonia NC 28052
City State Zip City State Zip
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s)are recorded
Deed Book 4739 Page 1811, 1814. 1817, 1820, 1823
Deed Book Page
114550, 305386, 139189,
10. Tax Map No. 139191, 222486 Block Lot No.
Page 1

PA B:
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity
Commonwealth Development Corporation
Name Name
7447 University Avenue, Suite 210
Mailing Address Mailing Address
Middleton, WI 53562
City State Zip City State Zip
404-406-6697
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.
Cogency Global,Inc.
Name
212 South Tryon Street,Suite 1000
Mailing Address Street Address
Charlotte,North Carolina 28281 866-775-0114
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.
Name7 ��,� �
Mailing Address Street Address
5 (3 iwic e '� .
City I (J r _A. l State w I Zip c ci Telephone Numberu a
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 pr ide corrected information should there be any change in the information provided
herein.
(M ‘Ma,ouqvi
Type Pint Name Title or Authority
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,S t e Date
I, 44-• , a Notary Public of the County of D -+ , State of-North- 'All SCtYtrfl
Garelina, hereby certify that I'-v-t appeared personally before me this day
and being duly sworn acknowledged that the abo y `��r �� ecuted by-hurt /-e�-
Witness hand an• notarial seal,this -5 .i •- `i�. , 2b a--a!
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