NCC222904_FRO Submitted (2)_20220812

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Gaston County
Gaston Natural Resources Department
\did 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
�.,%°Ru Stormwater
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 Stormwater Ordinance, before this form and an
acceptable Stormwater 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:
Project Name Carolina Riverside - Village D
2. Location of land -disturbing activity
City of Belmont Highway/Street Armstrong Ford Road
3. Approximate date land -disturbing activity will commence 03/01 /2022
4. Purpose of development (residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 86.67
27, 650.00 (87 acres - 8 acres (previously paid; overlap with `Carolina Riverside
6. Amount of fee enclosed $ Blvd. & South Fork Parkway'submittal) = 79 acres x $350/acre)]
7. Soil Erosion & Sedimentation Plan Filed? Yes X No
8. Landowner(s) of Record (Use blank page to list additional owners)
Belmont #1 US321/74 Bmass LLC
Name
Selwyn Avenue Suite 500
Mailing Address
Charlotte, NC 28209-1791
City State Zip
Telephone Number
Name
Mailing Address
City State Zip
Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book 3606 Page 0115
Deed Book Page
10. Tax Map No. 188444 Block NIA _ Lot No.
NIA
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PART B:
1. Person(s) or firm(s) who are financially responsible for this property.
Pulte Home Company, LLC
Name
11121 Carmel Commons Blvd. Suite 450
Mailing Address
Charlotte; NC 28226
City State Zip
[phone]
Telephone Number
Contact Name for Inspection Reports
Email Address
Telephone Number
Fax Number
If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of a North Carolina agent.
NIA
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 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).
agree to provide corrected information should there be any change in the Information provided
herein.
Jeremy Huntsman Director of Land Development
Type or-Pririt Name _._ Title or Authority
_ Y 11 /16/2021
Sig ture Date
!,A QO a Notary Public of the County of State of North
C o ina, hereby certify that use C\ appeared personally b re me this day
eing duly sworn acknowledged thal th6 above form was executed by him.
•�+��� my hand and notarial seal, this 1Ls day of
1 SEAL y Commission xpires
File: Financial ResponsibiRy Ownership Form.mw
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