NCC215215_FRO Submitted_20210920

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 N/A in the blank.)
Part AStockbridge at Tan lewood
1. Pro . ject Name g g _
2. Location of land -disturbing activity: County PasgUOtank City or Township Elizabeth City
Highway/Street Machelhe Island Lane Latitude 36.344030 Longitude-76.245750
3. Approximate date land -disturbing activity will commence:9/712021
4. Residential
Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 02 . acres
6. Amount of fee enclosed: $ 65 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),
7. Has an erosion and sediment control plan been tiled? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Adam Beck
E-mail Address abeck@
Telephone
757-905-5280 Cell u 804-304-5938
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hearndon Stockbridge Builders LLC 757-523-2569
Name
1001 Scenic Parkway Suite 104
Current Mailing Address
Chesapeake VA 23323
City State Zip
AUIi t 3
Telephone
1001 Scenic Parkway Suite 104
Current Street Address
Chesapeake VA 23323
City
State
Zip
10. Deed Book No, 1205 Page No, 157 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firms) 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.
NVR Inc. dba Ryan Homes [e-mail]
Name E-mail Address
4525 South Blvd Suite 100
Current Mailing Address
4525 South Blvd Suite 100
Current Street Address
Virginia Beach, VA 23452 Virginia Beach, VA 23452
City State Zip City State Zip
Telephone [phone] Fax Number 757-905-5281

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
Raleigh NC 27608
City State Zip
Telephone [phone]
Current Street Address
Raleigh NC 27608
City
Fax Number
State Zip
(b) li 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 name and street address of the Registered Agent:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Raleigh NC 27608
City State Zip
Telephone [phone]
E-mail Address
2626 Glenwood Avenue, Suite 550
Current Street Address
Raleigh NC 27608
City State Zip
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.
Division ManagerlVice President of Ryan Homes
Type or na a Title or Authority
II4I21
Signature Date
is t(J` t i r�fa P �r'n_, a Notary Public of the County of k ae vrA
State of 1G a�a rye; hereby certify that appeared
personally before me this day and being duly swo n acknowledg d that the above form was
executed by him.
Witness my hand and notarial seal, this qj r' ay of v v, 20�_
KRISTINALORAINEPENNINGTON
Notary Public
e COMMONWEALTH OFVA tar � 3 io 513
111 mbela Expires
�mber30,21nt My commission ices �L3 t)h(r?- f
Greg Knapp