NCC231054_FRO Submitted_20230418

—�� THE UNIVERSITY THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
l 1ii of NORTH CAROLINA UNIVERSITY COUNSEL
o f CHAPEL HILL 0 919-962-1219 I F 919-843-1617
Carolina Square I Suite 600A I Campus Box 9105
123 West Franklin Street I Chapel Hill,NC 27516-9105
MEMORANDUM
TO: GEORGE BATTLE III
VICE CHANCELLOR FOR INSTITUTIONAL INTEGRITY AND RISK MANAGEMENT
FROM: KRISTEN SIMONSEN LEWIS
ASSISTANT UNIVERSITY COUNSEL
DATE: MARCH 22,2023
RE: FINANCIAL RESPONSIBILITY FORM (EXPRESS PERMITTING)CAMPUS WIDE PARKING REPAIRS
MEMMO
Please find attached for date and notarizing the Financial Responsibility Form (Express Permitting) Campus
Wide Parking Repairs.
Please review, date,and notarize the document at your earliest convenience. Date and notarizing indication
is marked with a tape flag.Then please return the attachment to the desk of LaToya Gibbs.
If you have any questions,please feel free to contact me at 843-1829. Thank you for your assistance.

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name UNC Campus Wide Parking Repairs
2. Location of land-disturbing activity: County Orange City or Township Chapel Hill
Highway/Street440 W. Franklin St. Latitude(decimaidegrees) 35.9115 Longitude(decimaldegrees) -79.0621
3. Approximate date land-disturbing activity will commence: 6/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 14.82
6. Amount of fee enclosed $2000 + $1500 The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameJanet Clarke E-mail [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The University of North Carolina at Chapel Hill [phone] N/A
Name Phone: Office# Mobile#
Campus Box 1005 123 West Franklin St
Current Mailing Address Current Street Address
Chapel Hill NC 27599-1005 Chapel Hill NC 27516
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Deed Book No. 227 Page No. 1218-1221
Deed Book No. 5 Page No. 445-446
Deed Book No. 112 Page No. 363
Deed Book No. 112 Page No. 331

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)may be listed as the financially responsible party(ies).
The University of North Carolina at Chapel Hill [e-mail]
Company Name E-mail Address
Campus Box 1005 123 West Franklin St
Current Mailing Address Current Street Address
Chapel Hill NC 27599-1005 Chapel Hill NC 27516
City State Zip City State Zip
Phone: Office# [phone] Mobile# N/A
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Kimley-Horn and Associates, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Brian J. Michot, PE 919-678-4132 919-218-6339
Individual contact person (type or print) Phone: Office# Mobile#
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.
George E. Battle, Ill Vice Chancellor of Institutional Integrity and Risk Management
Type or print name Title or Authority
5 /a 3 .,/ - 3
Signat7 17 Date
I, Lortuvr. `v G ' , a Notary Public of the County of WA(Lc
State of North Carolina, hereby certify that ei S ii e, appeared personally
Cbefore me this day and being duly sworn acknowledged t at the above form was executed byhim/her
.
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Witness my hand and notarial seal, this '2•") day of L'4 kYC 1' I , 20 23
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Seal My commission expires 1 0 — V '"29
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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#

Prepared By: John T. ,.!ginning
NORTH CAROLINA
r-
ORANGE COUNTY 2" ` •a
THIS DEED, made and entered into this 14th day of
December, 1970, by and between JAMES R. FARLal and wif., LaBUE
FARLOW, parties of the first part; and NORTH CAROLINA BLUE CROSS
AND BLUE SHIELD, INC., party of the second part; all of Orange
County, North Carolina;
THAT WHEREAS, in August 28, 1962 James R. Farlow and
wife, LaRue Farlow conveyed certain property hereinafter describ-
ed to Hospital Saving Association and whereas the proper name
of Hospital Saving Association was at that time Hospital Saving
Association of North Carolina, Inc. and whereas the successor
corporation to Hospital Saving Association of North Carolina, Iic.
is North Carolina Blue Cross and Blue Shield, Inc., this deed is
made in order to correct the name of the said grantee, and
whereas parties of the first part claim no right, title or'
interest in or to said lands by reason of the matters and things
above set out, or in any other manner whatsoever;
NOW, THEREFORE, parties of the first part, for and in
consideration of the sum of TEN AND NO/100 (S10.00) DOLLARS, to
them in hand paid, the receipt of which is hereby acknowledged,
have remised and released and by these presents do remise, re-
lease and forever quitclaim unto the party of the second part
and its successors and assigns all right, title, claim, and
interest of the said parties of the first part in and to a
certain tract or parcel of land lying and being in the County
of Orange and State of North Carolina, in Chapel Hill Township,
and more particularly described as follows:
All that lot or certain parcel of land situated,
lying and being in the Town of Chapel Hill, N. C.
and being more particularly described as BEGINNING
at an intersection of West Rosemary Street and
Nunn Alley; running thence along the west property
line of Nunn Alley North 27° 46' West 228.7 feet
to a stake; running thence South 63° 45' West
• 174 feet to a stake in a branch; running thence
with said branch in a Southern direction 105
feet to a stake in the northern line of E. W.
Dawson property; running thence along said property
line North 63° 44' East 34.5 feet; running thence
South 30° 12' East 125 feet to a stake in the
North property line of West Rosemary Street; run-
ning thence along West Rosemary Street North 65°
BOON 227 ;#c 121i

{
25' East 112.5 feat to the point and place of
BEGINNING.
There is reserved by this deed a sewer or drain-
age easement across E. W. Dawson property. See
Deed Book 175 at page 238.
TO HAVE AND TO HOLD the aforesaid tract or parcel
of land and all privileges thereunto belonging to it the said
party of the second part and its successors and assigns free
and discharged from all right, title, claim, or interest of
• the said parties of the first part or anyone claiming by,
through, or under them.
IN TESTIMONY WHEREOF, said parties of the first part
have hereunto set their hands and seals the day and year first
above written.
I a+tlJc (SEAL)
dwtr't) (SEAL)
NORTH CAROLINA
COUNTY
/ ,L
;. .✓'- '- j• 7 ° ' r�. , a Notary Public of
said county, do hereby certify that JAMES R. FARLOW and wife,
LaRUE FARLOW, personally appeared before me this day and
acknowledged the due execution of the foregoing Quitclaim Deed.
Witness my hand and notarial seal, this the
day of December, 1970. �� L'f
/., •4:?7 =(sE r,} •
Notary Public X; ,
My commission expires: < - 3'' 7/
STATE OF NORTH CAROLINA—ORANGE COUNTY
THE FOREGOING CERTIFICATE:.61 OF L— eon F. Yates
A NOTARY VAXAMMati I'UBLIc OF THE OEIiIGNATEO GOVERNMENTAL UNITS IS I:CarACERTISTIO TO BE
CORRECT
F1LED
THIS THE_1�t11 OAv tic Dece•B•10e` _A4 M 7° J 6_^•v"n/n41 7 n _07f..'
GETTY DUNE HAYES.REGISTER OF OGEDS DEC7 e t /�I
ATS$•Ti7GZOHaUTY YE 17 i 35 FI I ,E U
RETURN!. COQp9r & Levine REGISTER OF OEBOs
$Cfl(JJ?iE}(:�}es
cf�IS" OF(t�M
BOOK 227 i,44rE 1219 ORarsGF COUNTY,H.C.

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Prepared. By: John T. Manning .---
NORTH CAROLINA ORANGE COUNTY
14th 70
This Dad, Made and entered into this, the day of December . lg , uy and between
NORTH CAROLINA BLUE CROSBAND BLUE SHIELD,. INC. successor by merger to
--110SVITALSAVINa-ASSOC/ATIM-010 -NORTH -CAROIINA, INC. .•
a corporauon duly treater and existing, under and by virtue of the laws of this Sc.party of the first part, to.....PTAT74....P.F. ...... ..... .
NORTH CAROLINA party.........,.. of the second part, 141fmcsseth:
That for and in consiecradon of the sum, of Tr3N AND 40/100- wihu (S10.00)
to it in hand paid the receipt of which is hereby fully tulnowledged,said party of thc first dart has given,granted,bargained and sold,and does
by these preients give.grant, bargain,sell and convey urto.• .........Ito........_........_......____.................said part Y of the second part and
it$ success,ors._Nam and anigns. the following_............... tracts or parce8 of land lying and being in
Chapel Hill -aomealp, in said County and State,hounded and&lathed as Mows, to-wit:
MACT 1: All that certain tract or parcel of land situated, lying and being on
the North side of West Franklin Street in the Town of Chapel Hill, North Carolina
and mote particularly described as BEGINNING at a stake in the North property line
Of West Franklin Street, the Southwest corner of the property conveyed to E. A. .
Brown by deed of M. J. Bright and wife by deed dated February 13th, 1948 and
recorded in the office of the Register of Deeds of Orange County in Deed Book 129
at Page 112 ; running thence along the North property line of the said street North
64° 30' East 185.8 feet to a point; continuing with the North property line oar the
Said street North 65° 45 ' East 150.2 feet to a stake; running thence North 22e 25 *
West 86.4 feet to a stake; running thence South 62° 49' West 39.8 feet to a stake;
running thence North 24° 12 ' West 216.5 feet to a stake in the South property line
of West Rosemary Street; running thence with the South property line of West Rose-
mary Street in a Westerly direction 136.7 feet to a stake, the Northwest corner
of that certain tract of land conveyed to Hospital Saving Association of North
Carolina, Inc. by deed of Glynn Fields and wife dated March 23, 1949 and recorded
in Deed Book 131 at Page 398, Orange County Registry; running thence in a Southerly
direction along the West property line of said tract described' in Deed Book 131
at Page 398, 119 feet to a stake; running thence South 56° 55 ' West 107.5 feet to a
stake; running thence South 85° 00' West 10.5 feet to a atake; running thence
South 25° 30' East 82.4 feet to a stake in the South side of a ten foot alley;
'running thence with the southern line of said alley South 64° 30 ' West 30 feet to
le stake; running thence South 25° 30' East 100 feet to the point of beginning,
...,
and being all of the property conveyed to Hospital Saving Association of North
Carolina, Inc. by deeds of Glynn Fields and wife recorded in Book 131 at Page 42,
i Orange County Registry, Book 131, Page 148, said Registry, Book 131 at Page 398,
said Registry, and by deed of Mabel R. Bason and husband recorded in Deed Book 15n,
Page 461, of said Registry, and by deeds of M. J. Bright and wife recorded in
I Book 131, Page 147, said Registry, and Book 160 at Page 1 of said Registry, and by
: deed of J. C. Scarborough and wife recorded in Book 196 at Page 399, of said
Registry, to which deeds reference is hereby made in order to incorporate by
ireference all the terms and conditions of said deeds as if fully set out herein.
1
, TRACT 2: All that certain lot or parcel of land situated, lying and being on the
! North side of West Rosemary Street in the Town of Chapel Hill, North Carolina and
1
being more particularly described as BEGINNING at an intersection of West Rosemary
IStreet and Nunn Alley; running thence along the West property line of Nunn Alley
North 27° 46' West 228.70 feet to a stake; running thence South 63° 45 ' West
1 174.00 feet to a stake; running thence South 38° 23 ' 30" East 103 .36 feet to a
i stake; running thence North 63" 26' East 34.50 feet to a stake; running thence
1 South 31° 28' East 125.00 feet to a stake in the North property line of West
Rosemary Street; running thence North 65° 25' East 112. 50 feet to the place of
beginning and being the same property conveyed by James R. Farlow and wife to
Hospital Saving Association by deed dated August 28, 1962 and recorded in Deed
Book 189 at Page 94, Orange County Registry. Reference is also made to that
1 certain Quitclaim Deed given by James R. Farlow to North Carolina Blue Cross and
: Blue Shield, /pc. ..dated December 14th, 1970.
BOOX 227 ?Acc1220

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To Have and to fold said trart 5.....,,or parce3S of land.togetlhct with ail privileges and appurtenances thereon and thereunto #
belonging.unto...:.... :..............aid part„ .........., of the second part and 1�S SLECCesS0 5.....................:acts. E
..,.,...._...... and assigns forever.
vile!,:sa;d• •ORTH CAROLINA BLUE CROSS AND BLUE SHIELD r INC. for itself and its
t .;::.Ls surcessQrs•
St:C{e:•+S+aYY co; it,°4'en? to and with said part of the second and ,........ s.,.... ..................................._.............:C?if and
ass gns thatit;i:v,sersed of said premises in fee,and has good right to convey the same in fee simplq that the same are free and clear of all
L.7cuthih-tste.es,and'tlitaf it will forever warrant and defend its said title to the save against the claims of all persons whomsoever.
'. ."`Zn•Tc.st;..-k?ny.I•begat, 'I he said party of the first part has caused this deed to be sealed with its cainmori seal,signed in its name'by its
L":,a Presiucut sirci'a;tcsteti by its i-stet ss,t Secretary,the day and year first above written. " e
•y*'..:. 17.'?ii'3�`'.•4 ' NORTH CAROLINA BLUE CROSS AND BLUE
xt:;cs=:' .•x SHIELD, xLSc. .
.41...;..,r;.mii,l :.......:......,........_.,..,._....:....r..... ......::... ......,_Secretary. fly '. .e. .,..._=! _"_. t - iresidew.
NORTII CAROLiNn, . :,..�f�= =• .................................._.........._County.
1 x
This is to certify that on this day personally cause befogs use .......J{:..C, I: 47.-4-:i--'....y ....'.[ _..._...... .......... with
whom I Sin per*.onalll..acquainted,who,being by me duly sworn, says Jhat ........,:..' ,e...a,....../.. L4't._, a t€:'.4rtom
Ls the President and that iS..•t.?....*".':..�=v.t.,r............:_.. .
he said l a
is Secretary of CAROLBLUEINC
the Corporation described in and which executed the foregoing instrument; that he knows the common seal of said Corporatidm:thrt the
seal fixed to said instrument is said common seal,and that the name of the Corporation was subscribed ds.reto by the sa,d Presides[, a:d
that said President and Secretary subscribed their names thereto and said common seat was affixed.all by order of the Eosrd of .Di:zctors of
said Corporation.and that said instrument is the act and deed of said Corporation. ;
.s.s„3• .,- ('P , e
Let said instrument,with this certificate.be registered. q� c
Witness my hand and../,.G'-4,,t.A. sea], this /.� /. ....... tl s ... ....... ........._._..:... . day,of i/.. ''-..19,.,1t%'.•:
.n^`l• L CY•�v7L.a..4.,�y...'7'i.r .t i_r..�.,,, K ?1/7•.", / .... .
J .........
Vr'ID'5't1 c.q.onr rv.i. r.n ntv.
l STATE OF NORTct CAROLINA—ORANGE COUNTY
THE FOREGOING CERT;FtCATE OF _Jewel L. Lloyd
A NOTARY x4a yl PUBLIC OF THE DESKCiN,tTED GOV RNt,,iIh3TAf.UNITS xS 1 t°d'1~,CEATIFIEO TO a
CORRECT
�7 FILED
THES THE:, 1 f th. DAY OF December a:�. i9 7Q. t3Q0i;/F� ?
BETTY JUNE HAYES, REGISTER OF DEEDS BY; DEC,��*''���t.-=,M=
DEC Il ti
3b ' '7
1 nETURN: Cooper & Levine REGISTEn of DEEDS
i _ BET.Y jt11`,E HAYES
---� BOOK 227 FAcd22 R c,sf'wF: cFzeFns
g R1S i'p,1~ $/ .)50,'C# GRAttGE COUNTY.t<r,c.
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