NCC216201_FRO Submitted (2)_20211206

C OUIV
.� Gaston County
m Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
01, Stormwater
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 Stormwater Ordinance, before this form and an
acceptable Stormwater 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 NIA in blank)
PART A:
1. Project Name Gastonia CFA
9
3
4
5
6
Location of land -disturbing activity
City Gastonia Highway/Street Cox Rd.
Approximate date land -disturbing activity will commence November 1, 2021
Purpose of development (residential, commercial, industrial, etc.) Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1.15 AC
Amount of fee enclosed $ 600
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Else blank page to list additional owners)
4
im
PP -COX RD LLC
Name
1422 Surtonwood Dr Ste 3000
Mailing Address
Gastcnis NC
City State Zip
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 4119 Page 1120
Deed Book 71 Page 99
Tax Map No. 210702
Block
Lot No.
Page t

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
Chick-Fil-A Inc
Name
5200 Buffington Rd
Mailing Address
Atlanta GA xxv
City State Zip
770-363-2163
Telephone Number
John Mark Wood
Contact Name for Inspection Reports
iohnmark.woodPcfacorp.com
Email Address
770-363-2163
Telephone Number
Fax Number
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
Will Whitley
Name
1518 E. Third Street, Suite 200
Mailing Address Street Address
Charlotte NC 28204 704-927-2888
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
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.
Typ�rint ame Title or Authority
Signat a Date
I, a N tary Public of the County of ,State ofWorth
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Gafofirra, heray certify that O appeared perso ally before me this day
and being duly sworn acknowledged that the ab ve for was exe uted b hi
Witness my hand and notarial seal, this w4 19 of R�` '2�.
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Notary
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File: Financial Responsibility -Ownership Form.mw
Page 2