NCC224017_FRO Submitted_20221208

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project NameAdam's Landing
2. Location of land -disturbing activity: CountyPaSquotank City or Township Elizabeth City
North Adama Landing Rd 36,294295-76,263343
Highway/Street Latitude(eacin,niasprea&) Lflrigltude(decimaldegrees)
3. Approximate date land -disturbing activity will commence: 11 / 15/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Residential
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5'3
6. Amount of fee enclosed: $600 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900),
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed N No ❑
B. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameAdam Beck E-mail [e-mail]
Phone: Office # 757-905-5280 Mobile it 894-304-5938
9.
Landowner(s) of Record (attach accompanied page to list additional owners):
Larrymore Organization 757-222-9410
Name Phone: Office #
6477 College Park Square
Current Mailing Address
Virginia Beach VA 23464
Current Street Address
Mobile #
City State Zip City State zip
449
10. Deed gook No. Page No. S44 Provide a copy of the most current deed.

Part B.
1, Company(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 proprietorship or if tho landowner(s) is
an individual(s), the namo(s) of the owner(s) may be fisted as the financially responsible party(W).
NVR Inc. dba Ryan Homes
Company Name
4525 South Blvd Suite 100
[e-mail]
E-mail Address
Current Mailing Address Current Street Address
Virginia Beach, VA 23452
City State Zip City State Zip
Phone: Office# 757-905-5280 Mobiles 757-905-5281
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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 F-mail Address
2626 Glenwood Ave, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608
City
State Zip
Phone: Office# 800-927-9800
City State Zip
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
Name of Registered Agent
4525 South Blvd Suite 100
Current Mailing Address
Virginia Beach, VA 23452
Cltv State
Phone: Office # 757-905-5280
Adam Beck
abeck@nVrinc,com
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
N10-
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 Knapp
Type o ri name
Sign ture
--------------------------------------------------------------
Division ManagerNice President
Title or Authority
la i l-RS-Z
Date
I,yzo 1L--' `"' Y� .,a Notary Public of the County ofy J [Q% (r!�JA ec& '
V1RGtfU)-"
State of North-Earel+aa, hereby certify that s�'C�~ KA')OP appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her,
Witness my hand and notarial sea], this �2S day of C-)C- Qbt - 2p 22-
Vcomm!
Seal
Jodie
Public
c 796t xpires 12G
Notary Public Tgti930(3
Commonwealth of Virginia
My Commission Explros May 31, 2026