NCC231326_FRO Submitted_20230505

Check if this project is ARPA-funded
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, including any
activity under a common plan of development of this size as covered by the NCGO1 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 N/A in the blank.)
Part A.
1. Project Name Lakes at Riverbend - Phase 1
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Brunswick City or Township Leland
Highway/Street Cedar Hill Rd Latitude(dedmal degrees)34.284 Longitude(dedmal degrees)-78.026
3. Approximate date land-disturbing activity will commence: 6/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):0.85 Ac
6. 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.
7. Has an erosion and sediment control plan been filed? Yes El Enclosed 2 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jon Vecchiarelli E-mail [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record(attach accompanied page to list additional owners):
Lakes at Riverbend LLC 919-868-3102
Name Phone: Office# Mobile#
506 Main St. Suite 300 Same
Current Mailing Address Current Street Address
Gaithersburg MD 20878 Same
City State Zip City State Zip
10. Deed Book No.4675 Page No.0794 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 all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies).
NVR Inc. [e-mail]
Company Name E-mail Address
2050 Corporate Centre Dr. 2050 Corporate Centre Dr.
Current Mailing Address Current Street Address
Myrtle Beach SC 29577 Myrtle Beach SC 29577
City State Zip City State Zip
Phone: Office# 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 [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave. Ste. 550 2626 Glenwood Ave. Ste. 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleight NC 27608
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Linda Snook
Name of Individual to Contact(if Registered Agent is a company)
(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.
Chris Riesch Division Manager, VP
Typeprt name Title or Aut ority
11 n/2--3
Si• r•• Date
I, ac 'b 41,aort ` 6 /df',' , a Notary Public of the County of / c44( Iir.t
State of North Carolina, hereby certify that r has PI o f C k appeared personally
before me this dayand beingdulysworn acktt6wled ed that the above form was executed byhim/her.
,j� 9
Witness my hand and notarial seal, this " clay of TT/ , 20a
ip
C_c.1,t/J //e764,1-- A-rtf
otary
Seal i /
My commission expires /UU�1 8
Jacob Adam Lanier
Notary Public,State of South Carolina
My Commission Expires 10/21/2031

Continued from Items 9 & 10 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 I 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 State Zip City State Zip
Phone: Office# Mobile#
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#