NCC221303_FRO Submitted_20220406

ovif Gaston County
Gaston Natural Resources Department
1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
Soil Erosion & Sedimentation Control
3 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.
PART A:
(Please type or print and, if question is not applicable, place N/A in b
1. Project Name Project Duo
2. Location of land -disturbing activity
City Uninc. Gaston County
3.
4.
5.
6.
Highway/Street NC-279 & Applewood Road
Approximate date land -disturbing activity will commence July 1, )021
Purpose of development (residential, commercial, industrial, etc.) Industrial
Total acreage disturbed or uncovered (including off -site borrow and waste areas)
Amount of fee enclosed $ 300 (to cover addtl acre)
7. Soil Erosion & Sedimentation Plan Filed? Yes x No
8. Landowner(s) of Record (Use blank page to list additional owners)
E
10.
Purvis Holdings, LLC
Name
PO Box 420
Mailing Address
Dallas, NC 28034
Cityy State Zip
7U4-778-5795
Telephone Number
5.7
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book Page
Deed Book Page
Tax Map No. Block Lot No.
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
Purvis Holdings, LLC
Name
PO Box 420
Mailing Address
Dallas, NC 28034
Cityy State Zip
7t)4-778-5795
Telephone Number
Todd Purvis
Contact Name for Inspection Reports
[e-mail]
Email Address
704-778-5795
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 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.
Todd Purvis
Type o Print Name
Si ure
Member
Title or Authority
7/12/2021
Date
I, 2- S\a Notary Public of the County of C Ci5'�7f) , State of North
Carolina, hereby certify that c: V \C-1 appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my nd and notarial seal, this �'�day of
PaSEAL I� My G'bmmission Expires
File: Financial Responsibility -Ownership Form.mw
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