NCC230712_FRO Submitted_20230316

Check if this project is AI;PA-funded ❑
FINANCIAL. RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
3
4.
Project Name Hickman$s Crossing- Lots 43,44,45,46
*11 this project involves American Rescue Plan Act (ARPA) funds, fist the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI),
Location of land -disturbing activity: County Brunswick
City or Township Calabash
Highway/Street Calabash Road Latitude(decimal degrees) 33.929 Longitude(declmal degrees) -78.61
Approximate date land -disturbing activity will commence: 2/13/23
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas):.513
Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 2 No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jon Vecchiarelli
Phone: Office #
E-mail Address [e-mail]
Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Ronnel S Parker Jr.
Name
PO Box 5967
Current Mailing Address
High Point NC 27262
City State Zip
843-241-0018
Phone: Office # Mobile #
502 Hickory Ridge Dr.
Current Street Address
Greensboro NC 27409
City
State
Zip
10, Deed Book No. 04756 Page No. 0768 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of ail responsible parties on accompanied page.) if the company is a solo proprietorship or if the landownor(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible pady(ies),
NVR INC.
Company Name
2050 Corporate Center Dr. STE 200
Current Mailing Address
Myrtle Beach SC 29577
City State Zip
Phone: Office #
vecchiaO..nvrinc.com
E-mail Address
2050 Corporate Center Dr. STE 200
Current Street Address
Myrtle Beach Sc 29577
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Ave Ste. 550
Current Mailing Address
Raleigh
City
NC
State
[e-mail]
E-mail Address
2626 Glenwood Ave Ste. 550
Current Street Address
27608 Raleigh
Zip City
Phone: Office # Mobile # [phone]
Linda Snook
Name of Individual to Contact (if Registered Agent is a company)
NC 27608
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone; Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
jDivision Manager
Type o ri t name Title or Aut ority
Signatur Date
I,.. , a Notary Public of the County of 1MA
State off Carolina, hereby certify that�$',r K i.��t appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seat, this _day of _t`Y r_C� , 20.
Seal
otary
My commission expi
Samantha K. Dionne
FNot,ary Public, State of South Carolina
Commission Expires 11/1Oj2037

Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
.Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No,
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City
Phone: Office #
State Zip City State
Mobile #
Zip
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone; Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #