NCC221572_FRO Submitted_20220422

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 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. Foxhaven
1. Project Name
2. Location of land -disturbing activity: County Pasquotank City or Township Elizabeth City
Highway/Street Ayla Ct Latitude 36.344278 Longitude-76.294928
3. Approximate date land -disturbing activity will commence:4/6/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1
6. Amount of fee enclosed: $ 100 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $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 Adam Beck E-mail Address [e-mail]
Telephone [phone] cell # 804-304-5938 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners).
North East Development 252-585-5857
Name Telephone Fax Number
1305 Campground Rd 1305 Campground Rd
Current Mailing Address Current Street Address
Elizabeth City, NC 27909 Elizabeth City, NC 27909
City State Zip City State zip
10. Deed Book No. 1320 Page No. 766 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. dba Ryan Homes [e-mail]
Name E-mail Address
4525 South Blvd Suite 100 4525 South Blvd Suite 100
Current Mailing Address Current Street Address
Virginia Beach, VA 23452 Virginia Beach, VA 23452
City State Zip City State Zip
Telephone [phone] Fax Number 757-905-5281

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
Name
E-mail Address
2626 Glenwood Avenue, Suite 550
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Current Street Address
Raleigh NC 27608
Raleigh NC 27608
City State Zip
City State Zip
Telephone [phone]
Fax Number
(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 Company
Name of Registered Agent
E-mail Address
2626 Glenwood Avenue, Suite 550
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Current Street Address
Raleigh NC 27608
Raleigh NC 27608
City State Zip
City State Zip
Telephone [phone]
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.
Greg Knapp Division ManagerNice President of Ryan Homes
Type gP pr ntAame
Sig
Title or Authority
z("o122
Date
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I, k1\ , a Notary Public of the Y of it ' a
( mm0yme0aky-, -4A\oio'
'8-tate_of Nor-th-_Garo it<La, hereby certify that appeared
personally before me this day and being duly swor acknow edged that the above form was
executed by him.
Witness my hand and notarial seal, this Q_day of a brUCL , 20_9,a
Notary
Seal U
My commission expires 2,19
Ashley Mason
Commonwealth of Virginia
NOTARY PUBLIC 7905021
My Commission Expires 03/31/2024