NCC232460_FRO Submitted (2)_20230816

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 N/A in the blank.)
Part A.
1. Project Name Varina Parking Lot
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Wake City or Township Fuquay-Varina
801 Durham Street 35.593064 -78.796853
Highway/Street Latitude(decimal degrees) Long ltude(decimaldegrees)
3. Approximate date land-disturbing activity will commence: 7/1/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .86
6. Amount of fee enclosed: $200.00 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matthew Poling E-mail Address [e-mail]
Phone: Office# 919-753-1035 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Town of Fuquay-Varina 919-552-1400 336-971 -4253
Name Phone: Office# Mobile#
134 N. Main Street 134 N. Main Street
Current Mailing Address Current Street Address
Fuquay-Varina NC, 27526 Fuquay-Varina NC, 27526
City State Zip City State Zip
10. Deed Book No. 019317 Page No. 02455 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 the landowner(s)is
an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies).
Town of Fuquay-Varina [e-mail]
Company Name E-mail Address
134 N. Main Street 134 N. Main Street
Current Mailing Address Current Street Address
Fuquay-Varina, NC 27526 Fuquay-Varina, NC 27526
City State Zip City State Zip
Phone: Office# 919-552-1400 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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.
Type or print name Title or Authority
�ly� c2 '2 . v -) -avaz
Signature ✓ Date
I, \--10.nY QN) 'LZ,1A a Notary Public of the County of WOrce.
State of North Carolina, hereby certify that iY10.' flew ). CON\Yl appeared personally
before me this day and being duly sworn acknowledged that the above fikm was executed by him/her.
Witness my hand and notarial seal, this � j day of m0,M , 20 1d3
Hannah Shaw c\1\Oli/O
Notary
sefsApTARY PUBLIC
Wake County,NC My commission expires VDzL-L, at.) Ao
My Commission Expires December 07,2026

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record.
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

BKO1931 /P(.5024bb °°"'^C L,`-"""' I , "�,
TAMMY L. BRUNNER
REGISTER OF DEEDS
PRESENTED & RECORDED ON
04-25-2023 AT 14:10:01
BOOK: 019317 PAGE: 02455-02459
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $0
Parcel ID: 0489366 _
Mail/Box to: Grantee
Prepared by: James S.Adcock III,PA, 135 N.Main Street,Fuquay-Varina,NC 27526
Brief
description Lot 2,BM 2021/1866
for the Index:
THIS GENERAL WARRANTY DEED ("Deed")is made on the LC? day of A-ptzi l 2023,by and between:
GRANTOR GRANTEE
Ample Storage Lake Worth,LLC Town of Fuquay-Varina
a Florida limited liability company a North Carolina municipal corporation
PO Box 608 134 N.Main Street
Smithfield, NC 27577 Fuquay-Varina,NC 27526
Enter in the appropriate block for each Grantor and Grantee their name, mailing address,and, if appropriate,state of
organization and character of entity,e.g.North Carolina or other corporation,LLC,or partnership. Grantor and Grantee
includes the above parties and their respective heirs,successors,and assigns, whether singular,plural, masculine,feminine or
neuter,as required by context.
FOR VALUABLE CONSIDERATION paid by Grantee, the receipt and legal sufficiency of which is acknowledged,
Grantor by this Deed does hereby grant,bargain,sell and convey to Grantee,in fee simple,all that certain lot,parcel of land or
condominium unit in the City of Fuqua--Varina,Wake County,North Carolina and more particularly described as follows(the
"Property"):
BEING all of Lot 2, containing 1.74 acres, as shown on that map entitled "Minor Subdivision Plat," prepared by
Bateman Civil Survey Company, dated 8-11-2021, and recorded in Book of Maps 2021, Page 1865, Wake County
Registry.
{N0392722.DOCX; 1}
Page 1
NC Bar Association Real Property Section Form No. 3©Revised 02/2021
Printed by Agreement with the NC Bar Association
Submitted electronically by "Cumalander Adcock, LLP"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Wake County Register of Deeds.

BK01931(I'GU24bti
Grantor reserves for itself its successors, and assigns two (2) ten foot by ten foot (10' by 10') Sign Easements
appurtenant,as follows:(a)the first sign easement located to the south of Durham Street and to the west of the parking
lot entrance for the Property from Durham Street,and(b)the second sign easement located to the north of Fayetteville
Street and to the east of the parking lot entrance for the Property from Fayetteville Street,in the locations set forth on
the site layout entitled "Varina Parking Lot—Fuquay-Varina, NC" as drawn by Donald L. Curry, Jr., PE of Curry
Engineering dated February 23, 2023, as such site plan is further referenced in Exhibit B, such exhibit being attached
hereto and incorporated herein by reference.
*The parties hereto agree that this conveyance is subject to the following restriction: The Property is to be used solely
for the purpose of ground-level public parking and related uses set forth on Exhibit A`Permitted Uses." Should the
Property be used for any other purpose, title to the Property shall revert, in fee simple, back to the heirs of Guy L.
Lampe and John H.Lampe,II.
All or a portion of the Property was acquired by Grantor by instrument recorded in Book 15684 page 2393.
All or a portion of the Property ❑ includes or ® does not include the primary residence of a Grantor.
A map showing the Property is recorded in Book of Maps 2021 Page 1865, Wake County Registry.
TO HAVE AND TO HOLD the Property and all privileges and appurtenances thereto belonging to Grantee in fee
simple. Grantor covenants with Grantee that Grantor is seized of the Property in fee simple, Grantor has the right to convey
the Property in fee simple, title to the Property is marketable and free and clear of all encumbrances,and Grantor shall warrant
and defend the title against the lawful claims of all persons whomsoever, other than the following exceptions:
1. Ad valorem taxes for 2023 and subsequent years.
2. Easements,restrictions, and rights of way of record affecting the subject Property
{N0392722.DOCX; 1}
Page 2
NC Bar Association Real Property Section Form No. 3 0 Revised 02/2021
Printed by Agreement with the NC Bar Association

13KU1931 (I'(30245/
IN WITNESS WHEREOF, Grantor has duly executed this North Carolina General Warranty Deed,if an entity by its
duly authorized representative.
. AMPLE STORAGE LAKE WORTH,LLC,
a Florida limited liability company
By:
Guy L.Lampe,Manager
STATE OF NORTH CAROLINA, COUNTY OF \Johns-hen
I Matz'nnAy Ou N( , a Notary of the above state and county, certify that the following
person(s)personally appeared before me on the (C day of A-pei L 2023 each acknowledging to me that
he or she signed the foregoing document,in the capacity represented and identified therein(if any):Guy L.Lampe.Manager of
Ample Storage Lake Worth.LLC, a Florida limited liability company.
Affix Notary Seal/Stamp 1 /1 ett ne/�
`,`tt'IuttIHglgrtt Notary ublic(Official Sig ture) 1
i �7�
♦`�``r`C��O '"'"'•�q'Q��i, My commission expires: "l-{¢.Zy
��`♦♦ J y 4• O'rri
6 C+ t
,'�ti N.C.
�fyIH1111N
{N0392722_DOCX; 1}
Page 3
NC Bar Association Real Property Section Form No. 3©Revised 02/2021
Printed by Agreement with the NC Bar Association

13KO1931 /NCUU2458
EXHIBIT A
PERMITTED USES
1. Underground utilities;
2. Overhead utilities within existing utility company easements;
3. Surface parking;
4. Landscaping not to exceed 12 ft in height;
5. Curb, gutter, and storm water devices;
6. Signage for public parking and way6nding;
7. EV charging stations;
8. Park benches;
9. Surveillance cameras; and
10. Bike racks.
11. Temporary events
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Page 4
NC Bar Association Real Property Section Form No. 3©Revised 02/2021
Printed by Agreement with the NC Bar Association

I3KU19 i1/I'U02459
Exhibit B
Location of Sign Easements
Sign Easement#1:
/W DEDICATION
H/C SIGN
(VAN ACCESS)
S' A.
m4
SIDEWALK
-
4, C_
SIGN ESMT 8'WI[
`* (10'x10') WALI,
i 4._ 5R _2_ - - FR2
/SY 1---____,/
?, , . —�— H/C SIGN -,---_____111111111111111.4411 .._
�
i 1 (VAN ACCESS) / 6,-
\� '. '�J 24"SOLID WHITE
. 1Z' STOP-BAR- -TRANSITION F
30"TO 24"C8(
�\ �l -R5.0' 28'FC/FC ,� ----TYP.EACH SI[
9' /
f
�R9.0' CR \� 10
Sign Easement#2: f--------7-
+�
11
' w%..ry
\\
1 ; I 17v_rh03'1+eva:�1+c - 18' 4 PARKS @ 9'
1 I Ili --IS 28'FC/FC 8
I 1 } i
12 PARKS @ 9' 1 1 «-i r 24"SOLID WHITE 1 _ �
�3 COMPACT PARKS @ 8' I i 1 I STOP BAR __ - BIKE RACI
I i - - (MODEL#7702 8'
STOP SIGN /*,0
; liGAME---
R1 1 115'PARKING SETBACK RAN DEDICATION --- � �i�—_
(PRIMARY FRONTAGE) �' �'� _-��_J�
nik
-"-'_- - - t WCR, / / -SIGN ESMT
- -— • - V \ , R25.0' ' (105E101
4LK -• - - . _ _ - - - R25.0' TRANSITION FROM 30"
TO 24"C&G,TYP.EACH
SIDE
8'WIDE STANDARD CROSS
WALK-NCDOT 1205.7
THIS MAP IS NOT A CERTIFIED SURVEY AND HAS NOT BEEN REVIEWED BY A LOCAL
GOVERNMENT AGENCY FOR COMPLIANCE WITH ANY APPLICABLE LAND
DEVELOPMENT REGULATIONS AND HAS NOT BEEN REVIEWED FOR COMPLIANCE WITH
RECORDING REQUIREMENTS FOR PLATS.
(N0392722-DOCX; 1)
Page 5
NC Bar Association Real Property Section Form No. 3©Revised 02/2021
Printed by Agreement with the NC Bar Association