NCC215218_FRO Submitted_20210917

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the blank.)
Part A. Fost Tract Planned Development
l . Project Name ___ —
4
3.
4.
5.
6
7
Location of land -disturbing activity: County Curr -- _ City or Township----
Highway/Street Survey Road Latitude36.530070 Longitude-76.182920
Approximate date land -disturbing activity will commence:
7/1/2021
Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas):2 acres
Amount of fee enclosed: $130 The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes. Nn _ Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Adam Beck
E-mail Address [e-mail]
Name
Telephone [phone] Cell #
804-304-5938 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Moyock Development LLC
252-435-2718
Name
Telephone Fax Number
417 Caratoke Highway, Unit D
417 Caratoke Highway, Unit D
Current Mailing Address
Current Street Address
Moyock, NC 27958
Moyock, NC 27958
City State Zip
City State Zip
10. Deed Book No. 1 524 Page No.456 ___. Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Inc. db_a Ryan Homes
[e-mail]
_NVR
Name
E-mail Address
4525 South Blvd Suite 100
4525 South Blvd Suite 100
Current Mailing Address
Current Street Address
Virginia Beach, VA 23452
Virginia Beach, VA 23452 —__
_
City State Zip
City State Zip
757-905-5280
Fax Number 757-905-5281
Telephone �__�

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Corporation Service Company
Name
E-mail Address
2626 Glenwood Avenue, Suite 550
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Current Street Address
Raleigh NC 27608
Raleigh NC 27608
City State Zip
City State Zip
Telephone [phone]
Fax Number` ---
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
a copy of the Certificate of Assumed Name. If the Financially Responsible
assumed name, attach
Party is a Corporation, give name and street address
of the Registered Agent:
Corporation Service Company
Name of Registered Agent
E-mail Address
2626 Glenwood Avenue, Suite 550
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Current Street Address
Raleigh NC 27608
Raleigh NC 27608
CityState Zip
City State Zip
Telephone [phone]
Fax Number_
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
the 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.
Greg
Type q
Sign
.i•
Division Manager/Vice President of Ryan Homes
Title or Authority
Date
---------------
a Notary Public of the C Qof _�r cif ��s�
11 tiro appeared
State of i g#r --o4na, hereby certify that _1---
personally before me this day and being duly swoftj acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this —!" —day of — _ 20_a�--
Notary
Seal d �
My commission expires_ A `t_
Ashley Mason
Commonwealth of Virginia
NOTARY PUBLIC 7905021
My Commission Expires 03/31/2024