NCC222874_FRO Submitted_20220811

°°°JV Gaston County
ft, -9 Gaston Natural Resources Department
o 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
;e 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 NIA in blank)
PART A:
2.
3
Project Name Carolina Riverside - South Fork Parkway Early Grading Package
Location of land -disturbing activity
City of Belmont Highway/Street Armstrong Ford Road
Approximate date land -disturbing activity will commence 01 /01 /2022
4. Purpose of development (residential, commercial, industrial, etc.)
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
6. Amount of fee enclosed $ 17,400.00
7, Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
Belmont #1 US321 /74 Byeass LLC
Name
Selwyn Avenue Suite 500
Mailing Address
Charlotte, NC 28209-1791
City State Zip
Telephone Number
Name
Mailing Address
6100
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 3606 Page 0115
Deed Book Page
10. Tax Map No. 188444 Block N/A Lot No. N/A
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Pulte Home Company, LLC
Name
11121 Carmel Commons Blvd. Suite 450
Mailing Address
Charlotte, NC 28226
City State Zip
[phone]
Telephone Number
Name
Mailing Address
City State Zip
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.
NIA
Name
Mailing Address Street Address
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.
Jeremy Huntsman
Type or Print Name
Director of Land Development
Title or Authority
8/10/2021
Date
I, , a Notary Public of the County of fate of North
ar ina, hereby certify that " ��!;2> ,c,� n appeared personally befo me thi���yi�
Wanitdness mduly swand nocktaroiwledaledthlsat lhe a advyfofm was executed bcy2 1m: t kelr�*��i��
�� ••Gomm• i
• s
N ,a SEAL Ily Commission E ires
File: Financial Responsibility-ai w , ip m.mw j
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Gaston County
I Gaston Natural Resources Department
\15� / 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Stormwater
4 �
a 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:
Q
3.
4.
5.
6.
Project Name Carolina Riverside - South Fork Parkway Early Grading Package
Location of land -disturbing activity
city of Belmont Highway/Street Armstrong Ford Road
Approximate date land -disturbing activity will commence 01 /01 /2022
Purpose of development (residential, commercial, industrial, etc.) Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 57.3
Amount of fee enclosed $ 20,300.00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
Belmont #1 US321/74 Bypass LLC
Name
Selwyn Avenue Suite 500
Mailing Address
Charlotte, NC 28209-1791
City State Zip
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 3606 Page 0115
Deed Book Page
10. Tax Map No. 188444 Block N/A Lot No
N/A
Page J

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
Pulte Home Company, LLC
Name
11121 Carmel Commons Blvd. Suite 450
Mailing Address
Charlotte. NC 28226
City State Zip
[phone]
Telephone Number
Contact Name for Inspection Reports
Email Address
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.
N/A
Name
Mailing Address Street Address
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.
Jeremy Huntsman
Type or Print Name
Director of Land Development
Title or Authority
8/10/2021
Date
I,! a Notary Public of the County of State of North
r ina, hereby certify that ppeared ersonall�befo methis,c�yn�`�111lr
and being duly sworn acknowledged that the above form was executed by him. �%%%
oOke
Witness my hand rial seal, this �a day of 2 Z�_ �t
XV1 go)13, �': NOT �5
of y SEAL y Commission pires .p ���
File: Financial Responsibility Owge o w
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Page r'q ountyt,�``'�

ff
tPulteGrouP . GASTON COUNTY
Vendor Number 4 6 lGAS100
Check Number 0071173754
Check Date 08/18/21
Invoice
Date
Co
Lot
Lot Address
Opt
Acct
Cat
Acct Cat Description
Amount
104005747564678
09/1 W21
Preacquisilion Land Costs
20,300.00+
�ts��
CD-
UVI-
TOTAL
20,300.00
■
, h k a e �OA
Chk
ulte" 0 harlotfe
zia5o' e chtree ad. b ti P
Suite 15, , , '. /I
*Pq tteG
rpqp� Atlanta; 30326
11oid,After,11.80 ayp
PAY
TWENTY THOUSAND THREE HUNDRED AND 00/100 DOLLARS
Bank of America
Customer Connection
Atlanta, L)ekalb County,OA
TO THE GASTON COUNTY
PO BOX 1578
ORDER OF GASTONIA, NC 28053
$***-120,300.00
0

A
IrPutteGroup--
GASTON COUNTY
Vendor Number 461GAS100
Check Number 0071173755
Check Date 08/18/21
Invoice
bate
Co
Lot
Lot Address
Opt
Catt
Acct Cat Description
Amount
1045595712OB747
08118I21
Preacquisilion land Costs
17,400.00+
x:* TOTAL'S*:`
17,400.00
M