NCC215798_FRO Submitted_20211019

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 A.
1. Project Name Springshire Creek (Lots 1 3J
2. Location of land -disturbing activity: County Union City or Township Indian Trail
Highway/Street Oak_Spr_inq Road Latitude 35.0990 Longitude -80.6568
3. Approximate date land -disturbing activity will commence: 812312021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.51 ac.
6. Amount of fee enclosed: $ 315.00 . The Express Permitting application fee is a dual charge. The
normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In
addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the
Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Luke Huther
E-mail Address lhuther(a�nvrinc.com
Telephone [phone] Cell # [phone] Fax # NIA
Landowner(s) of Record (attach accompanied page to list additional owners):
Oak Springs_ Aroject 1, LLC NIA NIA
Name Telephone Fax Number
10100 Innovation Dr —Suite 410 _10100 Innovation Dr., Suite 410
Current Mailing Address Current Street Address
Miamisburg, OH 45342 Miamisburg, OH 45342
City State Zip City State Zip
10. Deed Book No. 7913 Page No. 679 and Sk 7913 Pp 684. 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. lhuther(a�nvrinc.com
Name E-mail Address
_13924 Professional Center Dr., Suite 100_ 13924 Professional Center Dr., Suite 100�
Current Mailing Address _ Current Street Address
Huntersville NC 28078 Huntersville NC 28078
City State Zip City State Zip
Telephone [phone] Fax Number N/A
S:021122126-OAK SPRINGS SPRINGSHIREISPRINGSHIRE100CSIFRO SPRINGSHIRE.aOCX

DocuSign Envelope iD: 10E48 i81-9096-414F-130F1-689CF2=AIE
(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 Services Com an+ _ NIA
Name E-mail Address
2626 Glenwood Ave., Suite 550 2626 Glenwood Ave., Suite 550
Current Mailing Address Current Street Address
Raleigh, ,SIC 27608 Raleipn. NC 27608
City State City Stale lip
T e!acrcre [phone] =ax lur-.
(c) i; t:-a rinanGaily IRespcnsibie Par',/ fs a 'Partn=rsijp cr at'- 4erScn engaging in'business under ar.
assumed name, attach a copy of the Certificate of Assumed Name, I t"e Finarcial;y Responsible Pary
is a Corporation, give narre awd street address of the Registered Agent:
Corporation Services Com anv_ NIA
Name E-mail Address
2626 Glenwood Ave., Suite 550 2626 GlenwocdAve., Suite 530
Currant klaiiirg Address Current Street Address
Raleigh, NC 27608 _Raleigh. NC 27608
City State zip City State Zip
Telephone [phone] Fax i1IL:m..ber NZA
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Enginaer or other
consultant wh ,o can assist in providing any necessary informatlor, regarding the plan and its greparat.cn:
Harris Engineering wharris,0re-nc.c;m
Engineering Firm cr other ccnsu{taut c-mail Address
ilWayne M. Harris, P.E. C704) 334-1325 r'11A
Individual contact person (type or print) Telephone T Fa:< hlurrber
The above information is and cornet to 16he •^vest Cf my kncvAe'dge and belief and ay me under
cats {This rcrm Rust bei signed by t%e 'inancially R_espcnsitle Person iF an individual cr ^:is ?i;wr .ay in-faC , or
if nct an irdi,iduai, by an officer, director, car`i er, cr r❑ F r � h t'
- istz agent with aut cr'ty tc exec,.ie irstr.:n^ ems
-cr t:;e F1rarcially Respcnsible Parser). I agree to provide .,_=ected ' -c r c "ore ca ir:� r��,a��cn sh did -� ur,y ^^ar.ge
in the irfcrmaticn crcvrdeo+ i-erein.
I ~3aC—LS,J {e j,.n-2 a Tii!a cr Autrcnty
L 'r
jtect, {1ul�Ua 3/2/2021
Date
a Notary Public of the Count of
State of North Carolina, hereby certify that A' _LL-,,c° appeared personally
before me this day and being duly sworn ackno Iedged that the above form was executed by him.
A�44Witness my hand and notarial sea[, this �d day of 20 A /
t,,s111 iiirrr,
1�v Z:. t !. o'�r f Notary
Seal
i�1�C,Cla, btu �°jbli�
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A R 0
S:120210126 - OAK SPRINGS 1I 0QW110, RESS.00cX
My commission expires