NCC220256_FRO Submitted (3)_20220118

Continue - Financial Responsibility/Ownership Form
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 08461 Page 343
Book 29237 Page 55
Book 29237 Page 554
Book Page
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Koval Builders LLC
Address: 5960 Fairview Road Suite 341 Charlotte NC 28210
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: Valknorthwayhomes.com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Finn:
Address:
Telephone: Fax:
(Area Code)
Email Address:
(Area Code)
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual or by an
officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible company or entity, if not an individu .) J
Valentin Kovalenko b,,
Printed Name itle
Signature Dad
L At' OLif�/C,--YV bkk. S l" a Notary Public of the County
of State of__ALLcA`+2CI hereby
certify that 1_ e e. V 1, c4v Koo personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
- -,,If,
Witness my hand and notarial seal, this
Notary Signature:
My Commission expires: ! 1— [ (,
day of 20 . fl
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ENGINEERING & PROPERTY
MANAGEMENT
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