NCC231138_FRO Submitted_20230425

(*It
7°°! Gaston County
Gaston Natural Resources Department
1 Ch
erryville Ch e ryvill e Highway, Dallas, NC 28034 Telephone: [phone]
♦:;ult:i R Soil Erosion & Sedimentation Control
silt; Financial Responsibility/Ownership
` :Potstfi
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 Carolina Riverside - Village C
2. Location of land-disturbing activity
City of Belmont Highway/Street Armstrong Ford Road
3. Approximate date land-disturbing activity will commence 4/1/2023
4. Purpose of development (residential, commercial. industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 32.8
6. Amount of fee enclosed $ 16,200.00 (Check No. 0071176941. dated 10/3/2022)
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 Bypass LLC Pulte Home Company, LLC
Name Name
Selwyn Avenue Suite 500 11121 Carmel Commons Blvd. Suite #450
Mailing Address Mailing Address
Charlotte, NC 28209-1791 Charlotte NC 28226-4498
City State Zip City State Zip
[phone]
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s) or instrument(s) are recorded
Deed Book PB 097 Page PG 068
Deed Book 5354 Page 0111
10. Tax Map No. 307993 (Belmont #1) Block N/A Lot No. N/A
307989 (Pulte)
Page 1

PART B:
1. Person(s) or firm(s) who are financially responsible for this land-disturbing activity
Pulte Home Company, LLC
Name Name
11121 Carmel Commons Blvd. Suite 450
Mailing Address Mailing Address
Charlotte, NC 28226
City State Zip City State Zip
[phone]
Telephone Number Telephone Number
2. If the Financially Responsible Party is not a resident of North Carolina. give name and street
address of a North Carolina agent.
N/A
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.
Dan Rossi VP Land Planning and Development
Type or Print Name Title or Authority
3/27/2023
ature Date
I, 14 w r J CANS A 1(ti , a Notary Public of the County of I,-(*-14'1-1-- . State of North
Carolina, hereby certify that DAt-s p,nSf; appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
Witness my haM find notarial seal, this '1_Ta`-day of t1.M. ..v, , 2123 .
Notary SEAL My Commission Expires
—�i-+ File: Financial Responsibility-Ownership Form.mw
THOMAS J. PATANIA, JR.
NOTARY PUBUC
Lancaster County,South Carolina
Page 2
My Commission Expires January 9,2027