NCC231560_FRO Submitted_20230524

OWNERSHIP CHANGE
°��' Gaston County
,�, Gaston Natural Resources Department
o�1 I N 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
+.taRAL Ae, Soil Erosion & Sedimentation Control
O cm
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 N/A in blank)
PART A:
1. Project Name The Towns at McLean (McLean Masterplan)
2. Location of land-disturbing activity
City Belmont Highway/Street NC-273 Armstrong Road
3. Approximate date land-disturbing activity will commence 05/15/2023
4. Purpose of development(residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 18 ac
6. Amount of fee enclosed $ 5,400 ALREADY PAID BY NW LAKE WYLIE, LLC
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
NW Lake Wylie, LLC
Name Name
419 S Sharon Amity Road, Ste B
Mailing Address Mailing Address
Charlotte NC 28211
City State Zip City State Zip
(704) 650-6176 _
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book 4690 Page 2049
Deed Book Page
10. Tax Map No. 3581898841 Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s)who are financially responsible for this land-disturbing activity
Tri Pointe Homes Holdings, Inc.
Name Name
6325 Ardrey Kell Road, Suite 125
Mailing Address Mailing Address
Charlotte NC 28277
City State Zip City State Zip
(803) 431-6188
Telephone Number 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.
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
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.
Sean Schuttler Land Entitlements Manager
Type or Print Name Title or Authority
CS-..--e,-/-e—JT"--- — 101 /1°42 OP2
Signature Date
, r COO otary P lic of the County of t/u '/0'�1 , State of North
Caro , hereby certi that A -Q.,(- appeared personally before me this day
an ing duly sworn ac pwledged that t above forrn,yx a ecuted by him.
W' n ss m han � t 'ial seal, this dayof U 1/k. , 2D2-.3 .
inbey pi ,,, ,2_0_2y
otary SEAL My Comm ssion 6pires
AMBER M EGAN File:Financial Responsibility-Ownership Form.mw
NOTARY PUBLIC
UNION COUNTY
North Carolina Page 2
My Commission Expires MAY 2,2024