NCC233421_FRO Submitted_20231116

Check if this project is ARPA-funded i '
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 NCG01 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 KAI
Dd4Li- X Lid
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e.g., SRP--O-ARP-0121)below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County PM)SOS City or Township L Krrd6 bri
Highway/Street S'S144 1.)"Zt`lE. Latitudep i ) Longitude{de i degrees)
3. Approximate date land-disturbing activity will commence: 7 24 23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): 560 1i
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):. if°
6. Amount of fee enclosed: $ 1 00 OD . 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 0 Enclosed EL No
•
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
•
Name L ODOS' E-mail Address! `f 0 L. C.4 .. .
Phone: Office# 3 1Z-Sgen Mobile* (, y14 -1024f
9. Landowner(s)of Record(attach accompanied page to list additional owners):
me. &mksI ®c l444-4 0 33,6a4-52-6irt. 334-4zo -34'icq
Name Phone: Office# Mobile# •
Avacw gopas ` /25-40/40 t /r 7 , $0 if.10f
Current Mailing Address Current Street Address
)6644 Patrir Pit 272S47-1 6e6S4s6A4 s lye. zigo, t-
City State Zip City State Zip
10. Deed Book No. ez- Page No. 07 - Provide a copy of the most current deed.

2022 25 71
DAVIDSON COUNTY NC FEE$26.00
STATE OF NC REAL ESTATE EXTX
8500.00
PRESENTED&RECORDED
111301202210:04:36 AM
MICHAEL E.HORNE
REGISTER OF DEEDS
BY:CASEY L.RA NO
DEPUTY
BK: DE 2578
PG:481 -482
NORTH CAROLIN.A. GENERAL WARRANTY DEED
Excise Tax:$ )W
Parcel Identifier No, 1132130000003
Mail/Box to:Grantee: VO t to Ito g 1-1-qh t
This instrument nreparc i by: Jason Moss,a licensed North Carolina attorney, Delinquent taxes.if any,to be paid
by the closing attorney to the county tax collector upon disbursementof closing proceeds.
Brief description for the Index:
THIS DEED made this -*layof Npvember , 2022 ,by and between
GRANTOR GRANTEE
Leonard Road Partners,LLC Royal Homes of North Carolina,
LLC
PO Box 16168 141 Sasha Drive
High Point,NC 27261 Lexington,NC 27295
Enter in appropriate block for each Grantor and Grantee: name,mailing address,and,if appropriate,character of
entity,e.g.corporation oryartnership.
The designation Grantor and Grantee as used herein shall include said parties,their heirs,successors,and assigns,and
shall include singular,plural,masculine,feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is hereby
acknowledged,has and by these presents does grant,bargain,sell and convey unto the Grantee in fee simple,all that
certain lot or parcel of land situated in the City of Lexington Township,
Davidson County,North Carolina and more particularly described as follows:
•
Being all of Lots 3,4,5 and 6 of Kyndal ltun,as shown on the plat recorded in Plat Book 82,Page 87,in the
Office of the Register of Deeds of Davidson County,North Carolina.
The property hereinabove described was acquired by Grantor by instrument recorded in Book 2.3_90 page 1239.
All or a portion of the property herein conveyed does not include the primary residence of a Grantor.
A map showing the above described property is recorded in Plat Book 82 page 87 .
submitted electronically by "moss woods PLLC"
in compliance with North Carolina statutes governing recordable documents •
and the terms of the submitter agreement with the Davidson County Register of Deeds. •
ono,nlao-r,

TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging
to the Grantee in fee simple.
And the Grantor covenants with the Grantee,that Grantor is seized of the premises in fee simple, has the right to
convey the same in fee simple,that title is marketable and free and dear of all encumbrances,and that Grantor will
warrant and defend the title against the lawful claims of all persons whomsoever,other than the following exceptions:
IN WITNESS WHEREOF,the Grantor has duly executed the foregoing as of the day and year first above written.
•
Leonard Road Partners,LLC
(Entity Name)
By:
Print/Type Name&Title: 73-44'�14' J ' •
{
}
Mate of 0 i •
County of GuLigneL •
•
1, T a N Public of the above state and •
county,certify that � - ,4.! in his/her capacity as duly •
•
authorized M e r, of . :",nard tEoad Partners, LI,,C personally appeared
before me this day and at r e e same time and place all of the following occurred: (a)the aforesaid •
individual appeared in person before me;(b)the aforesaid individual was personally known to
me,or identified by my through satisfactory evidence; and(c)the aforesaid individual either
indicated and acknowledged d to me that the signature on the above document was his/hers or
signed the above document while in my physical presence, and while being personally observed •
by me doing so. •
•
I1ate•
221,
•
No Public
•
My Commission Expires •
arty
,m 1
800 1
Lif
�0 p MSNN`* �\
Bye,+, rco
7 f177 r , oil

Part rt`B.
i. 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 landowners)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Company Name E-mail Address
Pd c ICatt INZS--il401.11//4f.pr T ... fthit. 10 t
Current Mailing Address Current Street Address
,r
City State Zip City State Zip
Phone: Office# 1 —432- gc 443 Mobile# l$4 .'(Zo..314a 4
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)

i
(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.
Ripettxr tidotiaAtie.6 N✓ f$Gg—
Type or print nam Title or Authority
1/2-4/Z1 .•••
Signature Date
i •
, a Notary Public of the County of AR-t-A
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn ackno edged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of , 20'a?)
Dawn M Otremba (,__Notary SKIrARY PUBLIC
" 0' Guilford CountyNC
My commission expires
My CommIeeion lxpires August 2112026

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.
l
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#