NCC233578_FRO Submitted_20231205

Ct."!7A Gaston County
Gaston Natural Resources Department
(MI' 1303 Dallas-Cherryville Hwy. Dallas, N.C. 28034 Telephone: [phone]
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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 N/A in blank)
PART A:
1. Project Name Cr rues E+ekk,S Lo-1-S (-`{
2. Location of land-disturbing activity
City C as 4-on 44 Highway/Street Ski oup& Read
Latitude 36j.'Ll9 4 Longitude -8r, ►152
3. Approximate date land-disturbing activity will commence De.cem ber- 7.0 Z 3
4. Purpose of development (residential, commercial, industrial, etc.) R 44.+1 a
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) \ •2 7--
6. Amount of fee enclosed $ BOO
7. Soil Erosion &Sedimentation Plan Filed? Yes�— Enclosed a Non
8. Landowner(s)of Record(Use blank page to list additional owners)
B 6 C Grate r $,Ckaae a IA.c_
Name Name
12 Z 4 ameson 1JJ
Mailing Address J Mailing Address
2 k4.3IQ L., 8[foLl
City State Zip City State Zip
i61-1-30► - SYoI
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book N 1 A Page
Deed Book Page
10. Tax Map No. Sec a_}-i-uc,hr4 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.
D.a_. 0-0 Ora r1, l r\.c_ COCEAfr i ro
Name Cont t Name for Inspection Reports
'bc.n PrrrowriO e 1;31...,d , , C.V..ocen.+-i (kb @a2k_w41:3"..C..arn
Mailing Address Email Address
C,VO4w Nc, 4-,3 46o-8-7S- 8"'q
City State Zip Telephone Number
Q 3 0 • i3'7S - 0tobc-t i0IA
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 kent.
rJIA .
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.
Cr CarporcmAn,n S•--(s+e_vn
Name
1 Li0 I t\rti $cd C.A- *Sao i A-(1 f C_.+ ,lvc,..r�.+-u9 e_. co rv)
Mailing Address Email Ad ress
razati I irk t�C-- 0_1 ca I.S q/q-8 Z[-7 l 3 5
City State Zip Telephone Number
4. The above information is true and correct to the best of my knowledge and belief and was
provided by me under oath. (This form must be signed by the financially responsible person if an
individual or his attorney-in-fact, or, if not an individual, by an officer, director, partner, or
registered agent with authority to execute instruments for the financially responsible person). I
agree to provide corrected information should there be any change in the information provided
herein.
Cool (.O S e +-i n v O1� i .o r\ M SS A ES r'ech r v w�r� v►1i,�
Type r lint Nam Title or Authority
�,(' � 9 zz /Z 3
Signat Date
I, 1.o F, Cr040. a Notary Public of the County of iv"r Kleylbt , State of North
Carol' a, hereby certify that �$e�+,)tt appeared personally before me this day
and being duly sworn acknowledg 4d that the 5bove form was executed by him.
Witness my hand and notarial seal, this '-2" day of Sett I►er , 2021 .
-
� y
3 l � 1'l;;4
Netary Public, Ngr�h-,Carolina Commission Ex Tres
No, Mecklenburg Expires
Y P
My Commission Expires File:Financial Responsibility-Ownership Form.mw
March 03,2027
Page 2

Cramer Estates
Lot Parcel ID Pin
1 310676 3564813686
2 310677 3564813518
3 310678 3564812550
4 310679 3564812422