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Home My WebLink AboutNCG551243_owner name change (request)_20210625ROY COOPER Gurernnr MICHAEL S. REGAN Seeretan S. DANIEL SMITH Dircrmr NORTH CAROLINA Environmental Quality N UES Chi ltlf Cr}111�C l7 CUPerage OC) NC_1, 5000O OWNERSHIP CHANGE FOB I. Please enter the CoC number for which the change is requested. Certificate of Coverage 5 II. Please provide the following for the requested change (revised CoC). a. Request for change is a result of: Change in ownership of the residence/property Name change of the facility or owner If other please explain: b. CoC will be issued to (person's name or company name, if applicable): c. Owner: person legally responsible for CoC: d. Facility name (if applicable): e. Facility address: f. Facility contact person: [if different from Owner] NC. Cam`. S t LLC_ First MI V Title Last Permit Hold Mailing Address tV a-" City State Zip (C 1) '-130-a(o31 C Wtc(os pa►rtt 6 ili ( Phone E-mail Address 4345 uhN Address (414(c1- Q-7,5(0S CC��City First State Zip MI Last Phone E-mail Address III. Contact person (if different from the person legally responsible for the CoC) First MI Last } Title Mailing Address City State Zip Phone E-mail Address Revised 12/2018 NCG550000 OWNERSHIP CHANGE FORM Page 2 of 2 Will this permitted facility continue to discharge the same volume and type of wastewater as prior to this ownership or name change? Yes No (please explain) Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE INCOMPLETE OR MISSING: This completed application is required for both facility -name change and/or facility ownership change requests. [' Legal documentation of the transfer of ownership (such as a property deed, relevant pages of a contract, or a bill of sale) is required for an ownership change request. The certifications below must be completed and signed by the new applicant in the case of an ownership change request. APPLICANT CERTIFICATION I, , attest that this application for a name/ownership change has been reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not completed and that if all required supporting information is not included, this application package will be returned as incomplete. Signature Date PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO: Mr. Charles H. Weaver NC DEQ / DWR / NPDES 1617 Mail Service Center Raleigh, NC 27699-1617 Revised 4/2020 This instrument prepared by, Triangle Property Law, PC, a licensed North Carolina attorney. Delinquent taxes, if any, to be paid by the closing attorney to the Granville County, NC Tax Collector upon disbursement of closing proceedings. Excise Tax: $140.00 Type: CONSOLIDATED REAL PROPERTY Recorded: 6/8/2021 2:30:33 PM Fee Amt: $166.00 Page 1 of 3 Revenue Tax: $140.00 Granville County, NC Kathy M. Taylor Reg of Deeds BK 1844 PG 468 - 470 NORTH CAROLINA GENERAL WARRANTY DEED Parcel Identifier No.191100327397 Verified by County on the day of By: , 20_ Mail/Box to: Trianule Property Law. P.C.. 1051 Pemberton Hill Rd., Suite 102, Apex, NC 27502 This instrument was prepared by: Triangle PtopeftyJ.aw.P.C..1051 Pemberton Hill Rd.. Suite 102.Apex. NC 27502 Brief description for the Index: THIS DEED made this 26th day of May , 2021 , by and between GRANTOR COOPER-KELLY PROPERTIES, LLC A Georgia Limited Liability Company 1183 CAMERON CREEK MARIETTA, GA 30062 GRANTEE NC COLORS, LLC A North Carolina Limited Liability Company 4545 U.S. 15 OXFORD, NC 27565 Enter in appropriate block for each Grantor and Grantee: name, mai ing 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. 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 gram, 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 OXFORD Township, Granville County, North Carolina and more particularly described as follows: SEE EXHIBITAATTACHED. PREMISES ALSO KNOWN AS ADDRESS: 4545 U.S. 15, OXFORD, NC, 27565 The property hereinabove described was acquired by Grantor by instrument recorded in Book 1039 page 907 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 Page 1of2 NC Bar Association Form No. 3 ® 1976, Revised ® 1977, 2002, 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 submitted electronically by "Triangle Property Law, PC" in compliance with North Carolina statutes governing recordable documents and the terms of the submitter agreement with the Granville County Register of Deeds. My*+.. • lesion Ex Ail l) IARI, • on 4, 9rip04100 .4. NC Barla • ` ' _ 1976, Revisi Ran tcd by 'C Bar Assoda 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 tide against the lawful claims of all persons whomsoever, other than the following exceptions: THIS CONVEYANCE IS SUBJECTTO COVENANTS, RESTRICTIONS, AND EASEMENTS OF RECORD, AND AD VALOREM TAXES FOR THE CURRENTAND PRIOR YEARS. IN WITNESS WHEREOF, the Grantor has duly executed the foregoing as of the day and year first above written. COO -KELLY PROPER S. LLC By: jl (Entity ri Michelle Coo h 1 _per Print/Type Name & Title: br Managing Member By: (,SEAL) Print/Type Name & Title: Print/Type Name: (SEAL) Print/Type Name: Print/Type Name: (SEAL) By: (SEAL) Print/Type Name & Title: Print/Type Name: State of - County or City of I, 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 , 20_. My Commission Expires: Notary Public (Affix Seal) Notary's Printed or Typed Name State of - County or City of I, 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 ,20� My Commission Expires: (Affix Seal) Notary Public Notary's Printed or Typed Name State of fl_h C k - County or City of (5 r r {-o I, the undersigned Notary Public of the County or City of 6 LJ (+tjt-.se, and State aforesaid, certify that Michelle Cooper Kell. personally came before me this day and acknowledged that she is the Managing Member of COOPER KELLY PROPERTIES, 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, she signed the fo Ding instrument in its name n its behalf as its a+�ttiA .�,� Witness my hand and Notarial stamp or seal, this )i day of , 20 . • . SO (Z s33 Janet H Hogg NOTARY PUBLIC Bartow County, GEORGIA I1y4Q $ian Wet 210/12/2023 4 l-I o Notary Public 's Printed or Type This standard form has been approved by: North Carolina Bar Association — NC Bar Form No. 3 EXHIBIT "A" All of that certain tract or parcel of land lying and being situate in Fishing Creek Township, Granville County, North Carolina, and more particularly described as follows: Beginning at an existing iron pin situate in the western margin of the U.S. Highway #15 right of way, which said iron pin is also situate in the northeast corner of Temple Baptist Church, and being further located N. 12° 23' 09" E. 87.8 feet from N.C.G.S. ',Shady"; running .thence along the northern property line of Temple Baptist Church,, N. ,88° 44' 41" W. 180.08 feet to an existing •iron pin situate in the southeast corner formerly of Clayton (Deed Book 209, Page 241); thence along the eastern property line of Clayton, N. 110 16' 06" E. 149.63 feet to an existing iron pin situate in the southwest corner of the other property of Victor Montague; thence along the southern property line of Victor Montague, S. 75° 02' S1 " E. 176.03 feet to an existing iron pin set in the southern margin of S.R. #1134 as it intersects with the western margin of the U.S. Highway #15; thence along the western margin of the U.S. Highway #15, S. 11° 26' 31 " W. 106.88 feet to an existing iron pin, the point and place of beginning, containing 0.5236 acres, according to survey and plat of Ben L. Bryan, P.A., entitled "Survey for Janice E. Stafford" dated April 17, 1991. For further reference, see Deed of record in Book 955, Page 25, Granville County Registry. (4545 Hwy. 15, Oxford, NC 27565) FOR INFORMATIONAL PURPOSES ONLY PREMISES ALSO KNOWN AS ADDRESS: 4545 U.S. 15, OXFORD, NC, 27565 Parcel ID: 191100327397