NCC220693_FRO Submitted_20220211

Part A.
1. Project Name
TOWN OF NAGS HEAD
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
LLG
2. Location of land -disturbing activity: County a City or Township ce-,
Highway/Street S �� Latitude Longitude- "75 .�zaZIb(g
3. Approximate date land -disturbing activity will commence: eAQ , "I 1 7
4. Purpose of development (residential, commercial, industrial, institutional, etc.
tt
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): � -�-�Sklv
& Amount of fee enclosed (Commercial Projects Only)- 'Z.Q(j total
$50-00/up to 1 acre + $40/additional acre & revisions). The application fee is
7. Has an erosion and sediment control plan been filed? Yes U No
Enclosed-
8- Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name l' E-mail Address "'� - OGea
- com
Telephone!Z�5 - 9 M f) Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
' e I LLG
Name Telephone Fax Number
W. Vit
Current Mailing Address Current Street Address
G 17,
City State Zip City State Zip
10. Deed Book No.__ 2 ' �z page No () Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who is financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
f Ut — �+m ri[ mai .
Name E-mail Address
Dr s �me
Current Mailing Address Current Street Address
Na NG 21
City State Zip
Telephone
Mfn ber I' 141 SIB zd5
EY.MMW MeAGUM '. CGC~D w f n
SGm-e
City State Zip
Fax Number__ hGt2e-
5' shields '

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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:
\Aj k� E Sh t'ekjg, 00Y. yyw Ci j mail - (-Om
Name of Registered Agent E-mail Address
37-(0 V • V+ita„ Dyn6 Qr-, S arne,
Current Mailing Address Current Street Address
to Me VC-0-6 t46 2_1T59 same
City State Zip City State Zip
Telephone 9)EA' - 2,1W -17W Fax Number_ n0n:C _
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 attomey-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.
` 1 it IWW65 AJent
Type. or print name I Title or Authority
if
Signature Date
Notary Public
( — Z T -- Z —2—
I, V 1V1
C4 1 L Q a Notary Public of the County of 19iC
State of &)r� rf# .0 , hereby certify that !'� t Lt appeared
personally before me this day and being duly
sKworn acknowledged that the above form was executed by him.
Witness my hand al seal, this a day of <TAAJUf 20 ZZ
L Poi
dO Notary
SeaLI-0TA0I-
_= My commission expires o�
"UBIYO '
10111111110

BK 2546 PG 234 - 235 (2) DOC# 700105858
This Document eRecorded: 09/20/2021 03:12:35 PM
Fee: $26.00 Excise Tax: $1,900.00
Dare County, North Carolina Transfer Tax: $9,500.00
Cheryl L. House, REGISTER OF DEEDS
Dare County Land Transfer No.: 4855-21 Land Transfer Tax: 9500.00 1985 Sessions Law Chapter 670 (H8 215
NORTH CAROLINA GENERAL WARRANTY DEED
Excise, Tax: 11,9QQ.00 Land Transfer Tax: $9,500.00 LT# 4855-21
Parcel Identifier No. 008618000 & Verified by. County on the day of , 20,_
By:
Mail/Box to: Evans & Meads, PLLC
This instrument was prepared by: Casey & Robins, PC GAN1-0421
Brief description for the Index: LOT 11-15, BLK B-1, SEC 3, Resub of Roanoke Sound Shores
THIS DEED made this _...,20th day of. .:.....:.:...:..............September.._......__................_......................_. 2($1 , by and between
GRANTOR
GANNT DEVELOPMENT; LL..C, a North Carolina
limited liability company
PO. Box 97
Nags Head, NC 27959
GRANTEE
BLUE MOON FIVE 2, LLC, a North
Carolina limited liability company
326 W. Villa Dunes Dr.
Nags Head, NC 27959
Enter in appropriate block for each Grantor and Grantee: name, mailing address, and, if appropriate, character of entity, e.g.
corporation or partnership.
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.
W 1TNES SE' H, 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, parcel of land or condominium unit
situated in the City of Naas Head Naas Head Township, Dare ..,,,, County,
North Carolina and more particularly described as follows:
Lots 11, 12,13, 14 and 15, Block B-1, Section 3 of Roanoke Sound Shores as shown on plat of Roanoke Sound Shores, recorded in Plat
Book 2, Page 114 of the Dare County Public Registry, and being more particulary described thereon_
The property hereinabove described was acquired by Grantor by instrument recorded in Book 2413 page 178
All or a portion of the property herein conveyed — includes or X does not include the primary residence of a Grantor.
A map showing the above described property is recorded in Plat Book
Page 1 of 2
NC Bar Association Form No. 3 © 1976, Revised ©1977, 2002, 2013
Printed by Agreement with the NC Bar Association —1981
page 114
This standard form has been approved by:
North Carolina Bar Association — NC Bar Form No. 3

BK 2546 PG 235 DOC# 700105858
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 clear 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:
General utility easements and tights ofway of record;Ad valorem taxes subsequent to 2020; Restrictions and covenants ofrecord in Dare
County Registry.
IN WITNESS [WHEREOF, the Grantor has duly executed the foregoing as of the day and year first above written.
GANDT DEVELOPMENT. LLC
(Entity Name)
By:
Print/Type Name & Title: GmWi '"~, Member/Mana
By:
Printfl ype Name &
By:
Printflype Name & Title
State of - County or City of
1, the undersigned Notary Public of the County or City of
SEAL)
Print/Type Name:
SEAL
Print/Type Name:
(SEAL;
Print/Type Name:
(SEAL)
Print/Type Name:
and State aforesaid, certify that
personally appeared before me this day and acknowledged thedue
execution of the foregoing instrument for the purposes therein expressed. Witness my hand and Notarial stamp or seal this day of
My Commission Expires:
(Affix Seal)
_ Notary Public
Notary's Printed or Typed Nam
State of - County or City of _
1, the undersigned Notary Public of the County or City of and State aforesaid, certify that
personally appeared before me this day and acknowledged the due
execution of the foregoing instrument for the purposes therein expressed. Witness my hand and Notarial stamp or seal this day of
2U=
My Commission Expires:
(Affix Seal)
State of North Carolina - County or City of Dare
Notary's Primed or Typed Name
otary Public
1, the undersigned Notary Public of the County or City of.. nam _ and State aforesaid, certify that
GerWtticirts
is
he is the personally came before me this day and acknowledged that
__ Member/Mana er of GANDT DEVELOPMENT, LLC , a North Carolina or
_ corporation/limited liability company/general partnership/limited partnership (strike through the
inapplicable), and that by authority duly given and as the act of such entity, he signed the foregoing instrument in its name on its
behalf as its act and deed. Witness my hand and Notarial stamp or seal, this 20th day of Se tamber 2021
My Commission Expires: May ase _ 2025 Michael C. C��NotaryPublic
(Affix Seal) Notary's Printed or Typed Name
Page 2 of 2
NC Bar Association Form No_ 3 O 1976, Revised 01977, 200' 2013 This standard form has been approved by:
Printed by Agreement with the NC Bar Association —1981 Ncs1h Carolina Bar Associatoa —NC Bar Form No. 3