NCC215888_FRO Submitted_20211025

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Smith Douglas Homes
Address: (Physical Address): 4297 NC Highway 24/27 E, Suite B, Midland, NC 28107
(Mailing Address): PO Box 311 Midland, NC 28107
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
(Area Code)
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual or by an
officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible company or entity, if not an individual.)
James A. Gaskins
Printed
I,
President
Title
Date
a Notary Public of the County
of C,, Q FL4 S ,,// .State of � � ,hereby
cert� that ac, r 1e C � a S fro) S _ personally
appeared before me this day and under oath]acknowledge that this form was executed by him/her.
Witness my hand andpotarial seal, this t s f f'�k clay of Q 0 D be f- 20 a
Notary Signature:
My Commission expires:
�1
CHnRLoTrE-
ENGINEERING & PROPERTY
MANAGEMENT
\\I,I I III//
?� aoTAR r
PU13L�G
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpermits.charmeck.org
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