NCC242608_FRO Submitted_20240913

00QH4 Gaston County
�, • • Gaston Natural Resources Department
1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
tt 1 G
�,►ice AL boo- 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 Bellewood Towhnomes
2. Location of land-disturbing activity
City Gastonia Highway/Street Holland Memorial Church Road
3. Approximate date land-disturbing activity will commence September 2023
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 14
6. Amount of fee enclosed$5.600
7. Soil Erosion&Sedimentation Plan Filed? Yes x No
8. Landowner(s) of Record (Use blank page to list additional owners)
Bellewood Towns Asset LLC
Name Name
9935D Rea Road
Mailing Address Mailing Address
Charlotte NC 28277
City State Zip City State Zip
704-999-5655
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 5360 Page 52°
Deed Book Page
10. Tax Map No. 3526886129 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 landowner's 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.
Bellewood Towns Asset LLC
Name Contact Name for Inspection Reports
9935D Rea Road
Mailing Address Email Address
Charlotte NC 28277
City State Zip Telephone Number
704-999-5655
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.
Bellewood Towns Asset Management,LLC
Name
9935D Rea Road [e-mail]
Mailing Address Email Address
Charlotte NC 28227 704-998-1136
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).
agree to provide corrected information should there be any change in the information provided
herein.
Type or Print Name Title or Authority
i0102% 2 �
Signature Date
I, a Notary Public of.the County of CC.CAUex- , State of North
Carolina, hereby certify that A-Y\Ck.Q appeared personally be ore me this day
and being duly sworn acknowledged that the above form was executed by him.
W"ness my hand and notarial seal,thieS 3 day of( 5 2 , 2 G.-��. �ek
NotaryJ`J4 SEAL My mission Expires
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