NCC240689_FRO Submitted_20240312

Chuck it lids project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 NCG01 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 a-mall address or phone
number Is unavailable, place N/A In the blank.)
Part A.
1. Project Name Sharron Creek Crossing NVR Lots
'l/this project Involves American Rescue Plots Act(ARPA)funds, list Ilse Project Noose or Project
Number(e.g., SRP-D-ARP-0121)holm under which you wore approved for funding through the
Division of Water infrastructure(DWI),
2. Location of land-disturbing activity: County Brunswick City or Township Shallotte
Highway/Streell101d@n Beach Rd Latitude(decma3dc ees)33.9t310 LOngllude(decbnaldeprees) "7t3.3690
3. Approximate date land-disturbing activity will commence: 3/4/25
4. Purpose of development(residential,commercial, Industrial, institutional,etc.): Residential
6. Total acreage disturbed or uncovered(Including off-site borrow and waste areas): .72
6. Amount of fee enclosed:$ . 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 0 Enclosed Cl No 0
8. Person to contact should erosion and sediment control Issues arise during land-disturbing activity:
Name Jon Vecchiarelii Email Address jvecchia Cl nvr'If1c.com
Phone: Office,/ Mobile// 757-771-5055
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Ronne) S Parker Jr. 843-241-0018
Name Phone: Office lI Mobile/I
PO Box 5967 502 Hickory Ridge Dr.
Current Mailing Address Current Street Address
High Point NC 27262 Greensboro NC 27409
City State Zip City State Zip
10. Deed Book No.4775 Page No. 290 Provide a copy of the most current deed.

Part B.
1. Company(les)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 lndividual(s),the name(s)of the owner(s)may be listed as the financially responsible party(ies),
NVR INC. [e-mail]
Company Name E-mail Address
1106 Military Cutoff Rd. 2nd Floor 1105 Military Cutoff Rd. 2nd Floor
Current Mailing Address Current Street Address
Wilmington NC, 28405 Wilmington NC, 28405
City State Zip City State Zip
Phone: Office fl Mobile tf 757-771-5055
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Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form •
the Iandowner'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 Agenl:
Corporation Service Company linda.snook@cscglobal,Com •
Name of Registered Agent Email Address
2626 Glenwood Ave STE. 550 2626 Glenwood Ave STE, 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Phone: Office/E Mobile fE 866-403-5272
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
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•
Current Mailing Address Current Street Address •
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City State Zip City Slate Zip
•
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Phone: Office# Mobile ft
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•
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Name of individual 10 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 (he 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
corre d Information should there be any change In the information provided herein.
lid tj/(-S Division Manager
Typ or p it e Title or Authority
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Z4.,(2It
y. at Date
I, Sarr. .n�k.�, �;onne.. , a Notary Public of the County of �
s. CTc1�
State of 1Carolina, hereby certify that CID‘to (ADZ\'on 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 a 4 day of rehruart , 20 ay
Notary
Seel
My commission expi�
Samantha K. Dionne
Notary
Commission Expireso11/10/2031a

Continued from Items 9 & 10 in Pad A of the Financial Responsibility/Ownership Fonn for multiple
owners. Attach copies of this page as needed to list all landowners.
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Landowner 2 of Record:
Name Phone: Office# Mobile ii
Current Mailing Address Current Street Address •
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City State Zip City Slate Zip •
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office if Mobile Ii
Current Mailing Address Current Street Address
City State Zip City Stale Zip •
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record;
Name Phone: Office#I 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#I Mobile fI
Current Mailing Address Current Street Address
City State Zip Oily State Zip
Deed Book No, Page No. Provide a copy of the most current deed.

Continued from 11em 1 in Pail 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 Email Address
Current Mailing Address Current Street Address
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City State Zip City State Zip
Phone: Office i1 Mobile 11 •
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Company 3 Name E-mail Address •
Current Mailing Address Current Street Address
•
City Stale Zip City State Zip
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Phone: Office if Mobile# •
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Company 4 Name E-mail Address
}
Current Mailing Address Current Street Address j
City State Zip City State Zip
Phone: Office 1l Mobile if
Company 5 Name E-mail Address •
Current Mailing Address Current Street Address
City State Zlp City State Zip
Phone: Office 11 _.. Mobile 1i