NCC222527_FRO Submitted_20220714

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Gaston County
Gaston Natural Resources Department
1303 Dallas-Cherryville Hwy, Dallas, N.C. 28034 Telephone: [phone]
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 NIA in blank)
PART A:
1. Project Name Rocky Ridge Subdivision
2.
Location of land -disturbing activity
City Cherryville Highway/Street Rocky Ridge/Stoney Lane
3. Approximate date land -disturbing activity will commence
4.
5.
6.
Purpose of development (residential, commercial, industrial, etc.) residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas) 1-6 acres
Amount of fee enclosed $ 600.00
7. Soil Erosion & Sedimentation Plan Filed? Yes Yes . No
8. Landowner(s) of Record (Use blank page to list additional owners)
RE
10
Helmsman Homes, LLC
Name
116 Gasoline Alley, Suite 105
Mailing Address
Mooresville NC 28117
City State Zip
980-500-1251
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 5320 page 1066
Deed Book Page
Tax Map No. 211654,211653,211655,211660,211648
Block
Lot No.
Page 1

PART B:
1 _ Person(s) or firm(s) who are financially responsible for this land -disturbing activity
Landcrafters Sitework & Development
Name
PO BOX 3965
Mailing Address
Mooresville NC 28117
City State zip
980-500-1251
Telephone Number
Frank Kemo
Contact Name for Inspection Reports
[e-mail]
Email Address
704-517-9108
Telephone Number
704-677-7666
Fax Number
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
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.
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.
2— Yf r_wil!�
Type or Print Name Title or Authority
01
Signature Date
I, Q 14. Y-i r, n a Notary Public of the County of a&A State of North
Carolin , hereby certify thaj appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
WitneAs my hand and notarial seal, this 0rn day of - u'�e�, 209-7. .
N
iissron Expires
File: Financial Responsibility -Ownership Form.mw
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