NCC220911_FRO Submitted_20220301

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Cityof Gastonia- Municipal Operations Center
1. Project Name p p
2. Location of land -disturbing activity: CountyGaston City or TownshipGastonla
Highway/Street 1300 N Broad St Latitude 35.2808 Longitude-81 .1778
3. Approximate date land -disturbing activity will commence -.January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.);gOVernment
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.88 ac
6. Amount of fee enclosed: $400 The application fee of $�$5-6�'100per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes_ No Enclosed X
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ian Rosen E-mail Address [e-mail]
a
Telephone [phone]
Cell # 704.780.2020
Fax # na
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Gastonia 704-869-1037
Name Telephone
150 South York St (same)
Current Mailing Address
Gastonia NC 28053
City
Current Street Address
State Zip City
State
Fax Number
Zip
10. Deed Book No. 491 9 Page No.821 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Edifice LLC [e-mail]
Name E-mail Address
4111 South Blvd 4111 South Blvd
Current Mailing Address Current Street Address
Charlotte NC 28209 Charlotte NC 28209
City State
Telephone [phone]
Zip City
Fax Number
State
Zip

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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 Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax 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
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.
Tim Bender
Type• br rmt-rra7
:,,,
Signature
Project Manager
Title or Authority
11.5.21
Date
I, V1 Lkor I a f �A-c a Notary Public of the County of _MLc_kkf rnbytral
State of North Carolina, hereby certify that TIM Set-\Ok ' 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 5 day of >VUV2 Ic>O.r , 20 2-1
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Notary
My commission expires ^Pell 6 2()2'