NCC216248_FRO Submitted_20211109

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name. Stone Creek Townhomes (Lots_1- 24 & 180 -194, Bldgs. 1001.1005 & 1036 -1038)
Location of land -disturbing activity: County Union City or Township StaAings
Highway/Street Staillnps Road _Latitude 35.1001 Longitude-80,6716
3. Approximate date land -disturbing activity will commence: 111812021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.00 ac.
6. Amount of fee enclosed: $ 630.00 . 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 Jared KimakE-mail Address lkrmakd�nvrrnc. com ;.....
Telephone_ 7( 04) 815-3500 Cell # (704) 2499-0799 Fax # NIA
Landowner(s) of Record (attach accompanied page to list additional owners):
_Exeter Union Park Townes Developers, LLC NIA NIA
Name Telephone Fax Number
3716 National Drive, Suite 105 3716 Nationa!_Drive, Suite 105
Current Mailing Address Current Street Address
_R,aleiph, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
10. Deed Book No. 7840 1 Page No. 658 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. jklmak(@nvrinc.com
Name E-mail Address
10710 Sikes Place Suite 250 10716 Sikes Place, Suite 250
Current Mailing Address Current Street Address
Charlotte NC 28277 _ Charlotte, NC 28277
City State Zip City State Zip
Telephone_ [phone] Fax Number N/A
SA2021122133 - STONE CREEK (UNION PARK)MOC&FRO_EXPRESS-STONE CREEK.aOCX

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 NIA
Name E-mail Address
2626 Glenwood Ave. Suite 550 2626 Glenwood Ave., Suite 550
Current Mailing Address Current Street Address
Raleigh,.,NC,,, 27608 __ Ralei h NC 27608
City State Zip City State Zip
_ ( ) 403; 5272 , Fax Number NIA
Telephone 6
(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 CompanV, NIA
Name E-mail Address
_2626 Glenwood Ave., Suite 550 2626 Glenwood Ave. Suite 550
Current Mailing Address Current Street Address
Ralei h NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Telephone_L866)_403-5272 Fax Number NIA
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Harris Engineering
Engineering Firm or other consultant
Wayne M. Harris, RE
Individual contact person (type or print)
wharris(a.he-nc. com
E-mail Address
"_905-8618_ _NIA
Telephone 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.
q,e 1_ " i1DV61 a� ,
Title or Authority
I _.V2.2.1
Date
a Notary Public of the County of V 1) ill,. _
State of North Carolina, hereby certify that —
V 0�{A,'�/fGl.!/1 {�C�$,� appeared personally
before me this day and being duly sworn acknowledged that form was executed by him.
Witness my hand and notar`a`64iN, h)s
,the 'above
day of fn� MAW , 20 21
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