NCC240085_FRO Submitted_20240111

'.2.0. Gaston County
(WIT Gaston Natural Resources Department
at 1303 Cherryville Highway, Dallas, NC 28034 Telephone: [phone]
40") Soil Erosion & Sedimentation Control
(ite
Financial Responsibility/Ownership
. s.
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 Summit Ridge
2_ Location of land-disturbing activity
City Gastonia, NC Highway/Street Archie Whitesides Rd. &W. Franklin Blvd/Hwy 74
3. Approximate date land-disturbing activity will commence July 2022
4. Purpose of development(residential, commercial, industrial, etc.) Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) +/-12.0
6. Amount of fee enclosed $ 3,600
7. Soil Erosion &Sedimentation Plan Filed? Yes x No
8. Landowner(s)of Record(Use blank page to list additional owners)
Profile Homes-Summit Ridge, LLC i
Name Name
535 Plainfield Rd., Suite B
Mailing Address Mailing Address
Willowbrook _ IL 60527
City State Zip City State Zip
4312)898-4382 (117) g7,4 -i/1o91
Telephone Number Telephone Number
9. Indicate Deed Book and Page where deed(s)or instrument(s)are recorded
Deed Book 5297 Page 0475
Deed Book Page
10. Tax Map No. __ Block Lot No.
Page 1

PART B:
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity
Profile Homes, LLC
Name Name
176 Mine Lake Court, Suite 100
Mailing Address Mailing Address
Raleigh NC 27615
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. -
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.
Scott Erickson Division Manager _
Type or int Nam Title or Authority
0/2 ijs3
nature Date
I, arr\cr, a � , a Nota Pubfc of the County of Lk 1 O 1'� , State of North
Carolina, here y certify that 6 c.3 XLr(C appeared personally before me this day
being duly sworn acknowledged that th�above form was eecuted by him.
i ness my hand and notarial seal,this 1J ilgiqQfcew c, 2c?23 .
( I z UZL(
otaryY My Awnission Expires
File:Financial Responsibility-Ownership Form.mw
y Page 2
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10 cCW,N.,.