NCC220337_FRO Submitted_20220118

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 and/
or fax information unavailable, place N/A in the blank.)
Part A. EmbassySuites Hotel
1. Project Name
2. Location of land -disturbing activity: County Buncombe City or Township Asheville
Highway/Street Haywood Street Latitude35.5966796875 Longitude-82.5580062866211
3. Approximate date land -disturbing activity will commence: February 1 st
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.23
6. Amount of fee enclosed: $ 300 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Shaunak Patel E-mail Address [e-mail]
Telephone [phone] Cell # 919-768-3314 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PHG Asheville, LLC 919-854-2797 919-854-2798
Name Telephone Fax Number
4242 Six Forks Road, Suite 1600
Current Mailing Address
Raleigh, NC 27609
City State
10. Deed Book No. 5329
Current Street Address
Zip City State Zip
Page No.1573-1574 provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
PHG Asheville, LLC [e-mail]
Name E-mail Address
4242 Six Forks Road, Suite 1600
Current Mailing Address
Raleigh, NC 27609
City
State Zip
Telephone [phone]
Current Street Address
City State Zip
Fax Number 919-854-2798

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 State
Telephone
E-mail Address
Current Street Address
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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Shauna a Me
Type or print,'name
Signature
Manager
Title or Authority
01-13-22
Date
I, Lam//-?e T a Notary Public of the County of zyy w
State of North Carolina, hereby certify that :5 U appeared
personally before me this day and being duly sworn ac nowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of �IV41AR t/ 20_ YZ=
Notary
My Gomm. Exp•
I, �-2o2't My commission expires
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G'OL1n,.

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Type: CONSOLIDATED REAL PROPERT'
Recorded: 7/1/2015 4:07:54 PM
Fee Amt: $26.00 Page 1 of 2
Revenue Tax: $0.00
Buncombe County, NC
Drew Reisinger Register of Deeds
BK 5329 PG 1573 - 157
There are no delinquent taxes that are a lien
the parcel(s) described in the deed which the
Buncombe County Tax Collector is charged
with collecting.
07-01-2015�—
Date Deputy Tax Collector
Excise Tax: Exempt
Parcel Identifier No. 9649-20-1616 Verified by County on the day of , 20
By:
Mail/Box to: PYIG Asheville, LLC, 1255 Crescent Green, Suite 110, Cary, NC 27518
This instrument was prepared by: Michael C. Frue. Senior County Staff Attorney
Brief description for the Index: Plat Book 74, Page 37
THIS DEED made as of the Ist day of July, 2015 by and between
GRANTOR
Buncombe County, a body politic,
200 College Street, Suite 300
Asheville, NC 28801
GRANTEE
PHG Asheville, LLC,
a North Carolina limited liability company
1255 Crescent Green, Suite 110
Cary, NC 27518
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.
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 or parcel of land
situated in Buncombe County, North Carolina and more particularly described as follows:
BEING all of that 2.047 acre tract shown on that map entitled "Survey for County of Buncombe" by Danny R. Tolar and
dated May 29, 1999, and recorded in Plat Book 74, Page 37, Buncombe County, North Carolina Registry reference to
which plat is hereby made for purposes of description.
submitted electronically by "Manning Fulton"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Buncombe county Register of Deeds.
NC Bar Association Form No. 7 © 1/1/2010
Printed by Agreement with the NC Bar Association

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 forever.
The Grantor makes no warranty, express or implied, as to title to the property hereinabove described.
IN WITNESS WHEREOF, the Grantor has duly executed the foregoing as of the day and year first above written.
ri r ttest ' .Ot
Katy Hu hey Clerk to 1
STATE OF NORTH CAROLINA
COUNTY OF BUNCOMBE
�w
Board
BUNCOMBE COUNTY, a body politic and corporate
of the State of North Carolina
By: Dmx_�
David Gantt, Chairman
I, c.L �(Z, l,Z%�12 , Notary Public for said County and State, has personal knowledge of the identity of
Kathy Hughes, and hereby certifies that said Kathy Hughes, Clerk to the Board, personally appeared before me this day and
acknowledged that she is Clerk to the Board of Commissioners of County of Buncombe and that David Gantt is the Chairman of
the Board of Commissioners of Buncombe County, and that by authority duly given and as the act of the County of Buncombe, the
foregoing instrument was signed in its name by said Chairman, sealed with its official seal, and voluntarily attested to by herself as
its Clerk as the act and deed of the County of Buncombe, all by authority duly given by its governing body.
Witness my hand and notarial seal, this theZ.totday of June, 2015.
Notary Public
My commission expires: -MuJ,� Z&' -Z-0kct
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{CS: 00018025.DOCx}
NC Bur Association ronn No. 7 © 1/1/2010
Printed by Agreement with the NC Bar Association