NCC221913_FRO Submitted_20220519

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CARCHINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name---G �(
2. Location of land -disturbing activity: Jurisdiction W Ake (Wake Co. or Municipality)
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): i _
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): �i
6. Person to contact shoulderosionand sediment control issues arise during land -disturbing activity: 1_
Name �14\ 10 _N E-mail Address /to C/N,__ ` w �, "f ?1Vv- ► `"` y L"1i
Telephone -16J� Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Name(s) Teleph ne F c or E-ma' ddress
lg,)2 j
Current Mailing Address Current Street Address
W P Ai C _�� 27
City State Zip City State Zip
8. Deed Book No. Page No. %Z. Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Nam E-11ijil Address
/ 4c�l LW
IP�,,�►n-�
Current Mailing Address Current Street Address
1tc= ` -7�t
City State Zip
Telephone qd 6'f D �_q 5 -7IfX
City
Fax Number
State
Zip

(a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
C4CS' v'-1vX5cr
Type or print name
Signatur
Title or Authority
r0
Date
a Notary Public of the County of U.AAL l
State of North Carolina, hereby certify that , �a-sz n Nan Q\,) 1s(Dn appeared
personally before me this day and being duly sworn acknowledged that t e above form was executed by him.
Witness my hand and notarial seal, this day of f , 202)
C PC Y M
'•.•'$� ary
My commission expires �M2UZS
ti

3KO18756PGO2572
WAKE COUNTY, NC
TAMMY L. BRUNNER
REGISTER OF DEEDS
PRESENTED & RECORDED ON
10-20-2021 AT 13:45:34
STATE OF NC REAL ESTATE
EXCISE TAX: $360.00
BOOK: 018756 PAGE: 02572 - 02573
submitted electronicallyby "Newman & Newman Attorneys at Law"
In
dcthelterms ofttheosumitterhagreementewithvtheiWakeecountylRegisternof Deeds.
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $ 360.00
Parcel Identifier No. 0451361 Verified by County on the _ day of 20
By: C_
Mail/Box to: Grantee: 1422 Wall Rd. Wake Forest NC 27857
This instrument was prepared by: Elizabeth W. Newman Attorney At Law 304 Fast Jones StreetRaleigh, NC 27601
Brief description for the Index: LOT 11, Galloway
THIS DEED made this 14th day of October 202L by and between
Roy Taylor, a Separated Man as his Sale and
Separate Property
2028 Pleasant Forest Way
Wake Forest, NC 27587
GRANTEE
J&W Custom Homes, LLC
Property Address: 2028 Pleasant Forest Way
Wake Forest, NC 27587
Mailing Address: I422 Wall Road
Wake Forest, NC 27587
Enter inappropriate block for each Grantor and Grantee: name, mailing address, and, if appropriate, character of entity. e.
ty, g.
corporation or partnership.
The designation Grantor and Grantee as used herein shall include said parries, 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, parcel of land or condominium unit
situated in the City of Wake Forest Township, Wake
North Carolina and more particularly described as follows: County,
BEING all of Lot 11, Galloway Subdivision, Phase 5, as shown on that plat recorded in Book of Maps 2017, pages
2302-2303, as corrected by that plat recorded in Book of Maps 2017, page 2510, Wake County Registry.
The property hereinabove described was acquired by Grantor by instrument recorded in Book 18698 page 2505
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 2017 page—,... 2302 _
Page 1 of 2
NC Bar Association Form No, 3 01976. Revised 01977, 20D2, 2013
Printed by Agreement with the NC Bar Association —1981 This standard form has been approved by.
North Carolina Bar Association — NC Bar Form No. 3

3KO18756PGO2573
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:
1) 2021 Ad Valorem Taxes,
2) Uh'lity Easements and unviolated covenants, conditions or restrictions thatdo notntaterially affect the value ofthe Property
IN WITNESS WHEREOF. the Grantor hay duly executed the foregoing as of the day and year first above written,
(Entity Name) PrintlT peVN-.-, SEAL
r
By:
Print/fype Name &
(SEAL)
Print/rype Name:
Print/Type Name & Title: (SEAL)
Print/Type Name:
PrinuType Name &
(SEAL)
Pnnt/r pe Name:
- - - - - wunty or %-try or watce
Ro Ta 1. the undersigned Notary Public of the County or City of Hamett and State aforesaid, certify that
�� personally appeared before me s da and acknowledged thedue
execution of the foregoing instrument for the putpos art$�8r Witness my hand and Nostamp o this 18Bt day of
October 20 21 _
p(ARy'+ /
i 2 11 S
F
My Commission Expires: Apri121, 2025 B r() Jenna Bass
(Affix Seal) _ �G Notary Pu t
A U la\> �' : Notary's P m d or Typed Name
State of &LE Carolina - County or Ci[ftrgy�YVa.....
1, the undersigned Notary Public of the County o�tlls�eu 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 18th day of
. 20
My Commission Expires: Aar921,2025
(Affix Seal)
Jeans Bass Notary Public
Notary's Printed or Typed Name
the undersigned Notary Public of the County or City of and State aforesaid, certify that
personally came before me this day and acknowledged that
he is the of .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 day of 20
My Commission Expires: Notary Public
(Affix Seal)
Notary's Printed or Typed Name
NC Bar Association Form No, 3 4)1976. Revised O 1977. 2002, 2013 Page 2 of 2
Printed by Agreement with the NC Bar Association — This standard form has been approved by:
]981 North Canlina Bar Association -- NC Bar Form No. 3