NCC232461_FRO Submitted_20230815

Gaston County
Gaston Natural Resources Department
o .1 j�'1 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
4001,14 Soil Erosion & Sedimentation Control
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 Knoll
2. Location of land-disturbing activity
City TAU AAS Highway/StreetA LIZEEI . PAszt-`tIAX
3. Approximate date land-disturbing activity will commence- F. 23
4. Purpose of development (residential, commercial, industrial, etc.) commercial
5 . 98
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas)
6. Amount of fee enclosed $ 1, 800 . 00
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s)of Record (Use blank page to list additional owners)
Knoll Property, LLC
Name Name
2626 Glenwood Ave, Ste550
Mailing Address Mailing Address
Raleigh NC 27608
City State Zip City State Zip
704 . 737 . 1513
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s) are recorded
Deed Book C 9 5 Page 015
Deed Book Page
10. Tax Map No. Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s)who are financially responsible for this land-disturbing activity
Cox Schepp Construction, LLC
Name Name
2410 Dunavant St
Mailing Address Mailing Address
Charlotte NC 28203
City State Zip City State Zip
704 . 716 . 2100
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 certificatd'of assumed name. If the Financially
Responsible Part is a Corporation give name and street address of the Registered Agent.
Name
Mailing Address r 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.
Jim Schepp Owner
Type or Print Name Title or Auth rity
G -IG 2 3
S lure rici24772 Dat
I, Alexckfli NG12PX� a Noota�'y Public of the County of Mew IGn WY State of North
Carolina, hereby certify that ,_.\y'1 C)9? appeared personally bef re me this day
and being duly sworn acknowledged that tte,Akove forrrt was executed by him.
d and notarjal,seal„)his —day of ')h e , 202.?.j .
opt �pRA H A VS 120Z u
3�AL My Commission Expires
.'/ QZAR k U File: Financial Responsibility-Ownership Form.mw
g.
m0** Page 2
6." , - __ -
v8 URGG,,,,,
,,,
,,