NCC240547_FRO Submitted_20240229

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may inihate 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.0 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 NIA in the blank.)
Part A.
1 Proiect Name 114 Teague Dr.
2. Location ot land-disturbing activity: CountyMoore City or Township West End_Nc 27376
Highway.,Street 114 Teague Dr. LatItUde;c1,,,corw oegrew 35.25 L on gitud ee.magwe 779.60
3. Approximate date land-disturbing activity will commence: April 2024
4. Purpose of development(residential, commercial, industrial institutional, etc.), Residential
5 Total acreage disturbed or uncovered encluding off-site borrow and waste areas .5 acre
6. Amount of fee enclosed, 100.00 The application fee of S100.00 per acre (rounded
up to the next acre) $s assessed without a ceding 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 El Enclosed tE No 0
8 Person to contact should erosion anc sediment control issues arise during land-disturbing activity:
Name_Ralph Holbrook E-mail Address allseiyenc@gmalcoM
Phone. Office 0 Mobile [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners).
Ralph,Holbrook 910-690-1247
Name Phone: Office# Mobile#
2063 Seven Lakes S. 214 Devonshire Ave. w.
Current Mailing Address Current Street Address
West End NC 27376 West End NC 27376
City Slate Zip City State Zip
358
10, Deed book No 5979 Page No. Provide a copy of the most current deed.

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:
Sandra C. Holbrook 910-690-5908
Name Phone: Office# Mobile#
2063 Seven Lakes S. 214 Devonshire Ave. W.
Current Mailing Address Current Street Address
West End NC 27376 West End NC 27376
City State Zip City State Zip
Deed Book No. 5979 Page No. 358 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.

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).
Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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)

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#

(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.
Ralph Holbrook Owner
T o print name Title or Authority
2/12/2024
Sign a Date
I, Sherry P. aytnu.,v. , a Notary Public of the County of"Si ahryvvyi
State of North Carolina, hereby certify that I1 ph 1- oibr )ID appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this /2. day of Fcbruor'iir , 20 Z+
tttVpt��H//Norc1t�fnebtittr]N
TA
� Notary
Nota
f I �24.;�;. � My commission expires �/JI�

tsuvKaVru - I MUt Jot,
For Registration Register of Deeds
William Britton
Moose County. NC
Electronically Recorded
Marcy 1. 2023 9.43:42 AM
Book. 5979 Page 366 - 368 #Pages. 3
Fee $26 00 NC Rev Stamp 5256.00
Instrument# 202 3002508
Brief description for the index: Stamps:S256.00
LOT 3087, WILLOWDALE SECTION, SEVEN LAKES WEST—
PARCEL ID.00024334
This instrument was prepared by:The Gorenflo Law Firm, PLLC
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEW made this 71 MA day of February,2023, by and between,
GRANTOR l GRANTEE
CMS Capital Group LLC Ralph V. Holbrook,Jr. and wife,
a NC limited liability company Sandra C. Holbrook
MailinAddress Mailing Address:
2920 Forestville Road, Suite 100#3043 2063 Seven Lakes South
West End,NC 27376
Raleigh,NC 27616
Property Address:
114 Teague Drive
West End, NC 27376
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of
which is hereby acknowledged,have bargained and sold,and by these presents do grant,bargain,sell
and convey unto the Grantee in fee simple, all that certain lot, tract, or parcel of land situated in
Mineral Springs Township,Moore County,North Carolina,and more particularly described as
follows:
Being all of Lot 3087,Willowdale Section,as shown and delineated on that certain map
entitled "Willowdale Section,Seven I sakes West,Mineral Springs,North Carolina",by
I,arry IC. Allen,R.L.S.,which map is recorded in Plat Cabinet Number I,Slide Number
167-B, Moore County Registry, and to which map reference is made for a more
particular description.
submitted electronically by 'The Gorenflo Law Firm PLLC"
in compliance with north carolina statutes governing recordable documents
and the terms of the submitter agreement with the Moore County Register of Deeds.

The property hereinabove described was acquired by Grantor by instrument recorded
in Book 5979,Page 358, Moore County Registry.
All or a portion of the property herein conveyed does not include the primary residence of a Grantor.
TO HAVE, AND TO HOLD the aforesaid lot, tract, or parcel of land, and all privileges and
appurtenances thereto belonging to the said Grantee in fee simple; subject, however, to the
exceptions, reservations and conditions herein above referred to.
And the Grantor covenants with the Grantee, that Grantor is seized of said premises in fee simple
and has the right to convey in fee simple; that the 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 except: ad valorem taxes for the current year(prorated to the date of closing);
utility easements;unviolated covenants,conditions and restrictions that do not materially affect the
value of the property being conveyed herein; and such other encumbrances as may be assumed or
specifically approved by Grantee.
The designation Grantor or Grantee as used herein shall include the singular as well as the plural and
the masculine, feminine or neuter gender may be read in either the masculine, feminine or neuter
gender or a combination thereof as the context may require in order to accurately refer to the person
or persons first named hereinabove as Grantor and Grantee.
*** THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK ***

IN WrYNESS WHEREOF,the said Grantor has hereunto set his hand and seal,or if Corporate,has
caused this instrument to be signed in its Corporate name in the ordinary course of business by its
duly authorized officer,pursuant to authorization from the Board of Directors,or if Limited Liability
Company(Company),in its Company name in the ordinary course of business by its duly authorized
manager,or pursuant to authorization from its members, the day and year first above written.
C S Capital GroupLC
• (SEAL)
onnor Swanson, Member/Manager
STATE OF NU-h Carol; hk
COUNTY OF , to wit:
I certify that the following person(s)personally appeared before me this day, and each
acknowledging to me that he or she signed the foregoing document in the capacity indicated:
Connor Swanson, Member/Manager of CMS Capital Group LLC, a NC limited liability
company, being so authorized.
Witness my hand and notarial seal this ,7 day of February, 2023.
Notary Public
PLACE NOTARY SEAL INSIDE THIS BOX ONLY! PGNA
(Printed Name of Notary)
HAYDEN PAULS
j
My Commission Expires:C-A/ / ii>k00
Notary Public
Wake County, NC
Commission Expires 02-15-2027