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HomeMy WebLinkAboutNCC224055_FRO Submitted_20221214Gaston County Gaston Natural Resources Department 1303 Cherryville Highway, Dallas, NC 28034 Telephone: 704-922-4181 3%at Soil Erosion & Sedimentation Control : Financial Responsibility/Ownership x 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 PROJECT SPENCER MOUNTAIN FA 3 Location of land -disturbing activity City GASTONIA Highway/Street SCALEY BARK ROAD Approximate date land -disturbing activity will commence 6/1/22 4. Purpose of development (residential, commercial, industrial, etc.) INDUSTRIAL BUILDING UPFIT 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 2.10 AC. 6. Amount of fee enclosed $ 900.00 7. Soil Erosion & Sedimentation Plan Filed? Yes x No 8. Landowner(s) of Record (Use blank oaae to list additional owners) 0 10 NP GASTONIA INDUSTRIAL LLC Name 4825 NW 41ST STREET, SUITE 500 Mailing Address RIVERSIDE MO 64150 City State Zip 816-888-7380 Telephone Number Name Mailing Address City State Zip Telephone Number Indicate Deed Book and Page where deed(s) or instrument(s) are recorded Deed Book 5185 Page 0733 Deed Book Page Tax Map No. PARCEL # 304670 Block Lot No. Page 1 PART B: 1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity Bryan Builders, LLC. Name 220 Freeman Street Mailing Address Longwood FL 32750 City State Zip 407-948-3384 Telephone Number Name Mailing Address City State Zip Telephone Number If the Financially Responsible Party is not a resident of North Carolina, give name and street address or a North Carolina agent. Scott A. Bryan Name 57 Silver Fox Trail Mailing Address Street Address Beech Mountain NC 28604 407-948-3384 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 Part is a Corporation give name and street address of the Registered Agent. Name Mailing Address Street Address 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). I agree to provide corrected information should there be any change in the information provided herein. Scott A. Bryan Type or Print Nam oQ ´┐Żl Signature President Bryan Builders - Owner / Agent Title or Authority 3/7/22 Date I, Nlchollah Green , a Notary Public of the County of , State of North Carolina, hereby certify that Scott A. Bryan 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 7th day of March 12022 LL 5/16/24 NotarNr SEAL My Commission Expires NICHOLIAH GREEN File: Financial Responsibility -Ownership Form.mw NotaryioState of Florida Commission i GG 888839 ? My Commission Expires May 16, 2024- Page 2