NCC224055_FRO Submitted_20221214

Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
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 �l
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