NCC221737_FRO Submitted_20220505

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. BaileyMills Townhomes
I. Project Name
2. Location of land -disturbing activity: County Union City or Township Stallings
Highway/Street 2933 Matthews -Indian Trail Rd. Latitude 35.0986 Longitude-80.6821
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.26
G. Amount of fee enclosed: $ 500.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
$. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brodie Scanlin E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Stallings Townes, LLC N/A
Name Telephone Fax Number
608 Briar Patch Terrace 608 Briar Patch Terrace
Current Mailing Address Current Street Address
Waxhaw, NC 28173 Waxhaw, NC 28173
City State Zip City State Zip
10. Deed Book No. 7814 Page No. 443 & 448 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 orfirm 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
10710 Sikes Place, Suite 250 10710 Sikes Place, Suite 250
Current Mailing Address Current Street Address
Charlotte, NC 28277 Charlotte, NC 28277
City State
Telephone [phone]
Zip City
Fax Number N/A
State
Zip

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 Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number NIA
(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 NIA
Name of Registered Agent E-mail Address
2626 Glenwood Ave., Suite 550 2626 Glenwood Ave., Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Telepho
[phone] Fax Number NIA
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.
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Signatu
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Title or Authority
3, 2 2:>, 2.7 -
Date
I, a Notary Public of the County of UAAj g V1
State of North Carolina, hereby certify that PC.S s appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial this 2�
Seal
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day of MwV1A4 , 20 22-
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Notary
My commission expires