NCC224096_FRO Submitted_20221213

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. Cherry Grove Townhomes (Lots 6 - 10)
1. Project Name
2
Location of land -disturbing activity: County Cabarrus
Rainbow Dr 35 4921
City or Township Kannapolis
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence: Dec. 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.26
6. Amount of fee enclosed: $ 100.00 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Luke Huther E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # NIA
.01
Landowner(s) of Record (attach accompanied page to list additional owners):
Westbrook Kannapolis, LLC [phone] NIA
Name Telephone Fax Number
8320 Judy Witt Lane 8320 Judy Witt Lane
Current Mailing Address Current Street Address
Vienna, VA 22182 Vienna, VA 22182
City
10. Deed Book No.
State
15759
Zip
City State
Zip
Page No. 80 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] (Luke Huther)
Name
13924 Professional Center Dr., Suite 100
Current Mailing Address
Huntersville, NC 28078
City State Zip
Telephone [phone]
E-mail Address
13924 Professional Center Dr., Suite 100
Current Street Address
Huntersville, NC 28078
City State Zip
Fax Number NIA

DocuSign Envelope ID: 5ED72711-AI=00-4695-85F1-9B7C56C29181
(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 N/A
Name
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raleigh, NC 27608
City State
Telephone [phone]
E-mail Address
2626 Glenwood Ave., Suite 550
Current Street Address
Raleigh, NC 27608
Zip City State
Fax Number N/A
z
(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 N/A
Name of Registered Agent
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raleigh, NC 27608
City
State Zip
Telephone [phone]
E-mail Address
2626 Glenwood Ave., Suite 550
Current Street Address
Raleigh, NC 27608
City State Zip
Fax Number N/A
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.
® sent name Title or Authority
�� H4"A 10/13/2022
Signature Date
l V�V�4�e' � 6�z out , a Notary Public of the County of L(Od_ob')
State of North Carolina, hereby certify that e,K fh eA ,) appeared
personally before me this day and being duly s orn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this �'-�'kday of Dbe-4� �, 20 A;.
ANNETTE N GAC - 1 Notary
otary Public, North Carolina
Sea Lincoln County
My Commfsslon Expires My commission expires �1o?`tlaUa'�
February29, 2024