NCC224036_FRO Submitted_20221208

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
by
he Act before this
No person may initiate any land -disturbing activity
control plan have been completeddand tapproved by he Land
and an acceptable erosion and s
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the approprta e
Regional office. (Please type or print athe nd, ifthequestion is not applicable or the email address or phone
number is unavailable, place NIA k
Part A.
1. Project NamePeIICan Point
Pas uotank Elizabeth City
G City or Township
2. Location of land -disturbing activity: County 36,267-76.19259
Highway/StreetPejlCaCl Pant Drive Latitude(decimaldegrees) �LongltUde(decimaldegrees)
1 11'I 5I22
1 Approximate date land -disturbing activity will commence. Residential
4. Purpose of development (residential, commercial, industrial, institutional, etc.): 2.42
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
$300($200already senUsend€rgS100mora) The application fee of $100.00 per acre (rounded
6. Amount of fee enclosed: $
up to the next acre) it (Example: 8.10-acre application fee is $900).
s assessed without a ceiling amoun
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise decland-disturbing nVrinc Com
Name
Adam Beck E-mail Addressab
Phone: Office #
757-905-5280 Mobile # [phone]
g. Landowner(s) of Record (attach accompanied page to listaddowners):
The Village I 9098 Mobile#
Phone: Office #
Name
1432 Weeksville Road
Current Street Address
Current Mailing Address
Elizabeth City State zip
City State zip City
10, Deed Book No.
1449 Page No. 526 Provide a copy of the most current deed.

Part B.
1. Cornpany(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprieforsfiip or if the landowner(s) is
an individual(s), the names) of the owners) may be listed as the financially responsible pady(ies),
NVR Inc. dba Ryan Homes
Company Name
4525 South Blvd Suite 100
current Mailing Address
Virginia Beach, VA 23452
City State Zip
Phone: Office # 757-905-5280
[e-mail]
1r-mail Address
Current Street Address
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity,
2, (a) If the financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Corporation Service Company
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 state Zip
City State Zip City
Phone: Office # 800-927-9800 Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NVR Inc. dba Ryan Homes abeck [e-mail]
Name of Registered Agent E-mail Address
4525 South Blvd Suite 100
Current Mailing Address Current Street Address
Virginia Beach, VA 23452
City
State Zip City
State Zip
Phone: Office # 757-905-5280 Mobile #
Adam Beck
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed !Name.
Company DBA Name
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(s)
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 party). I agree to provide
corrected information should there be any change in the information provided herein.
Greg K
Type or in
Signa
Division ManagerNice President
Title or Authority
l0 2e 2Z
Date
--------------------------
C-AA
1\ILWk(i , a Notary Public of the' of a—
GuywmnWecO- A �%��tia. j a appeared personally
i�a, ereby certify that
before me this day and being duly sworn acknowled d that the above form was executed by him/her.
Witness my hand and notarial seal, this � day of 20;),-&,__
Notary
Seal
My commission expires
Ashley Mason
Commonwealth of Virginia
NOTARY PUBLIC 7905021
My Commission Expires 03/3112024