NCC223774_FRO Submitted_20221108

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Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
.•t°"`� 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 N/A in blank)
PART A:
P11
3.
Project Name Rosewood Village
Location of land -disturbing activity
City Dallas Highway/Street - 5R 2271 - Rosewood Drive
Approximate date land -disturbing activity will commence October 1, 2022
4. Purpose of development (residential, commercial, industrial, etc.)
residential subdivision
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
6. Amount of fee enclosed $ previously paid
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
BBC Rosewood LLC
Name
7224 Jameson Way
Mailing Address
Stanley NC 28164
City State Zip
704-607-5059
Telephone Number
E
10
11.82 acres
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 5359 Page 908
Deed Book Page
Tax Map No. 171850
Block
Lot No.
Page I

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
BBC Rosewood LLC
Name
7224 Jameson Way
Mailing Address
Stanley NC 28164
City State Zip
704-607-5059
Telephone Number
Contact Name for Inspection Reports
Email Address
Telephone Number
Fax Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
Name
Mailing Address Street Address
City State Zip Telephone Number
3. 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.
Steve Bailey
Type ant Name
Signatu
President
Title or Authority
13.- Tq •- LZ
Date A /
1,J1, a jry blic of the County of �_N State of,PlerHT
Carolina, hereby certify that appeared personally before me this day
and being duly sworn acknowledged that t bove for as executed by him.
Wit ess my hand nd n tarial seal t ' � , 2G2 Z�
P5 H. LEppF
otary sot:. y (%mmission Expires
NOTARY File: Financial Responsibility -Ownership Form.mw
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