NCC233309_FRO Submitted_20231106

Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance
No person may initiate any land-disturbing activity on one or more acres as covered by the ordinance before this form and
an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County
Environmental Management Department,
Part A Parcel ID Number
124-046
1.Project Name*
Liberty Grove - Infill Development
2.Location of land-disturbing activity(Righway/Street)*
Lentz Road
Latitude Longitude
35.5664 -80.5730
3.Approximate date land-disturbing activity will be commenced
12/1/2023
4.Purpose of development(residential,commercial,industrial,etc.)
Residential
5.Approximate acreage of land to be disturbed or uncovered*
0.19
6,Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity*
[phone]
Luke Huther
*this information will be made available on the Rowan County Planning&Development website.
Email Address
[e-mail]

7.Landowner of Record Landowner of Record
Platinum NC, LLC
Name Name
Current Mailing Address Current Mailing Address
210 Ocean Ave.
Lakewood, NJ 08701
8.Recorded in Deed Book Number Page Number
1413 675
Part B
1.Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this land-
land-disturbing activity disturbing activity
NVR, Inc.(dba Ryan Homes)
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
13924 Professional Center Dr.,Suite 100
Huntersville, NC 28078
Phone Number Phone Number
[phone]
a.If the Financially Responsible Party is not a resident of North Carolina,give name and street address of a North Carolina
Agent.
Name of Agent Name of Agent
Corporation Service Company
Current Mailing Address Current Mailing Address
2626 Glenwood Ave.,Suite 550
Raleigh,NC 27608
Phone Number Phone Number
[phone]

b.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 the name and street address
of the Registered Agent.
Name of Registered Agent
Corporation Service Company
Current Mailing Address Current Street Address
2626 Glenwood Ave., Suite 550
Raleigh,NC 27608
Telephone Number Telephone Number
[phone]
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 correctional information should there be any change in the information provided herein.
Name Title or Eule_tie:Dliviektc4 lob (V of
Signature Date
t4,) „rzn
I, m*At, NMap,a Notary Public of the County of �--f n°df 11 State of North Carolina,hereby
certify that ' erR� P i &13it) appeared personally before me this day and being duy sworn acknowledged that the
above form was executed by him/her.Witness my hand and seal of Notary,this IJ ay of ei' ,20L
Notary My commission expires
alaoy
Notary Public, North Carolina
Seal Lincoln County
My Commission Expires
Checklist February 29,2024
Download a copy of the Erosion and Sedimentation Control
Plan Checklist(PDE)