NCC223893_FRO Submitted_20221121

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 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.
QUAIL GLEN (PARTRIDGE VILLAGE) LOTS 108, 109, 110, 111, 112, 113, 114, 115 (Deed Book and Page number: 4153:928)
1. Project Name
2. Location of land -disturbing activity: County HARNETT city or Township LILLINGTON
S R-2215 35.45851-78.79985
Highway/Street Latltude(decimal degrees) LOnglttide(decimal degrees)
3. Approximate date land -disturbing activity will commence: 10/15/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.605 ACRES
6. Amount of fee enclosed: $ 200 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 ❑ Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name BRIAN ROMANCHOK E-mail Address [e-mail]
Phone: Office # 919-987-1930 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PENNY ROAD DEVELOPERS, LLC. 919-418-4343
Name Phone: Office # Mobile #
10305 PENNY. RD. 10305 PENNY. RD.
Current Mailing Address Current Street Address
RALEIGH NC 27606 RALEIGH NC 27606
City State Zip City State Zip
10. Deed Book No. 4153 Page No. 928 Provide a copy of the most current deed.

Part B.
I. 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 orif the landowner(s) is
an individual(s), the names) of the owner(s) maybe listed as the financially responsible partyfies).
NVR, INC.
Company Name
5734 TRINITY RD. STE 200
Current Mailing Address
RALEIGH NC 27606
City State Zip
Phone: Office # 919-987-1946
[e-mail]
E-mail Address
5734 TRINITY RD. STE 200
Current Street Address
RALEIGH NC 27606
City State Zip
Mobile #
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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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.
JOE SCHMIDTKE
T or print name
gnature
VICE PRESIDENT
Title or Authority
8112/22
Date
a Notary Public of the County of V
Jj
State of North Carolina, hereby certify that JOE SCHMIDTKE 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 seal, this 12th day of August 2022
Glaire
tAR
•
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p&B OC. '
Cbl�
My commission expires

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
Deed Book No
Landowner 3 of Record:
Name
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 4 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 5 of Record:
Name
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
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 9 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 #