NCC223723_FRO Submitted_20221102

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. The Farm (Lots 780 - 786 & 807 - 860)
1. Project Name
2
3
Location of land -disturbing activity: County Cabarrus
Shiloh Church Rd 35 4615
City or Township Kannapolis
Highway/Street . Latitude Longitude.
Approximate date land -disturbing activity will commence: Oct. 2022
-80.7706
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.05
6. Amount of fee enclosed: $ 1 ,000.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ryan Kozusko E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Farm P4 Partners, LLC [phone] NIA
Name Telephone Fax Number
1401 East 7th St. Suite 200 1401 East 7th St. Suite 200
Current Mailing Address
Charlotte, NC 28204
City State Zip
10. ❑eed Book No. 15657 Page No.
51
Current Street Address
Charlotte, NC 28204
City State Zip
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.
NVR, Inc. (dba Ryan Homes) [e-mail] (Ryan Kozusko)
Name
13924 Profession Center Dr., Suite 100
Current Mailing Address
Huntersville, NC 28078
City State Zip
Telephone [phone]
E-mail Address
13924 Profession Center Dr., Suite 100
Current Street Address
Huntersville, NC 28078
City
Fax Number NIA
State Zip

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
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raleigh, NC 27608
City
State Zip
Telephone [phone]
NIA
E-mail Address
2626 Glenwood Ave., Suite 550
Current Street Address
Raleigh, NC 27608
City State Zip
Fax Number NIA
(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 name and street address of the Registered Agent:
Corporation Service Company NIA
Name of Registered Agent
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raleigh, NC 27608
City State
Telephone [phone]
E-mail Address
2626 Glenwood Ave., Suite 550
Current Street Address
Raleigh, NC 27608
,Zip City
Fax Number N/A
State Zip
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.
RAWM L44 ttolho tro" - After
Typ or print n Title or Authority
ignature Date
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a Notary Public of the County of l 'w
State of North Carolina, hereby certify that � W �" 0 u , .( appeared
personally before me this day and being duly Awarn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day 20
Notary
deal NoiarY Pubilc _
Ntecklenbusg Count'! r .
My commission expires