NCC233121_FRO Submitted_20231019

$; Gaston County
Im a Gaston Natural Resources Department
0 . • ''r 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
4. Soil Erosion & Sedimentation Control
iiita
is\c_____),,T ., 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 Life Storage-Gastonia
2. Location of land-disturbing activity
City Gastonia Highway/Street E.Hudson Blvd
3. Approximate date land-disturbing activity will commence 11/17/2023
4. Purpose of development (residential, commercial, industrial, etc.) commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 3.70
6. Amount of fee enclosed$1600
7. Soil Erosion &Sedimentation Plan Filed? Yes X No attached
8. Landowner(s) of Record (Use blank page to list additional owners)
Gaston County Family YMCA
Name Name
615 W Franklin Blvd.
Mailing Address Mailing Address
Gastonia NC 28052
City State Zip City State Zip
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 4863 Page 989
Deed Book Page
10. Tax Map No. 115541 Block Lot No.
Page 1

PART B:
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity. NOTE: if FRP is not the
Landowner of Record Part A: 8., include with this form the landowners signed and notarized written consent for the
applicant to submit a draft erosion and sedimentation control plan and to conduct the anticipated land disturbing
activity.
Legacy Pointe Gastonia,LLC Jamie Rolewicz
Name Contact Name for Inspection Reports
19354 Watermark Dr.Suite 102 [e-mail]
Mailing Address Email Address
Cornelius NC 28031 704-905-0335
City State Zip Telephone Number
704-905-0335
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.
Name
Mailing Address Email 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 Party is a Corporation give name and street address of the Registered Agent.
Jamie Rolewicz
Name
19354 Watermark Dr.Suite 102 [e-mail]
Mailing Address Email Address
Cornelius NC 28031 704-905-0335
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.
Jamie Rolewicz Manager
T pe-oY' t-l�}a�n Title or Authority
et a jaW E01
Signature Date
I, (-CAM"- ,c1 ZT.wt/ , a Notary Public of the County of 1(11.14I I , State of North
Carolina, hereby certify that gWti 2 /14•�e o��, [4 4.aappeared personally before me this day
and being duly sworn ackno ledged that the above form wag(executed by him.
Witness hand and notarial seal,thi\ 2 a 4 f tr ,2 9)23 .
N ary .. v re ell Ic iy Commissio4 Expires
File:Financial Responsibility-Ownership Form.mw
County =
My Comm. Exp.
- 01-28-2027 Q
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