NC0036692_Owner (Name Change)_20220524

ROY COOPER
MICHAEL S. REGAN
LINDA CULPEPPER
Water Resources
LNVINONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
i. CURRENT PERMIT INFORMATION:
Permit Number: NC00 3/ IS /(..0 /l /a or NCG5 ` '
/
/ / /
1. Facility Name: a ,1 Q * y 1'l(�( W yU 1 I) RECEIVED 2
II. NEW OWNER/NAME INFORMATION:
MAY 2 4 2022
1. This request for a name change is a result of
✓a. Change in ownership of property/company NCDEQIDWRINPDES
/ nb. Name change only I,�
V c. Other (please explain): 1-h t 1QS SktOU CAQ-\
2. New owner's name(name to be put on permit):
Mid Century Revitalization, LLC
3. New owner's or signing official's name and title: Larry Spelts
(Person legally responsible for permit)
Member
(Title)
4. Mailing address: 80 Line Street City:Charleston
State:sC Zip Code 29403 Phone: (843 ) 297-8385
E-mail address: [e-mail]
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center!Raleigh.NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc.gov/abouu'di v i sions/water-resourcesiwater-resources-perm i is/wastewater-branch!npdes-wastewater-permits

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I, Larry Spelts , 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 and attachments are not included, this application
package will be returned as incomplete.
Date:/9 /14j41 �QZZ-
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ I DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/2017
1

N.C. Department of Environmental Quality
Division of Water Resources
Electronic Signature Agreement
Federal regulations require that electronic documents must have valid electronic signatures if Title 40 of
the Code of Federal Regulations requires handwritten signatures on the paper documents they replace.
Valid electronic signature refers to an electronic signature on an electronic document that has been
created with an electronic signature credential.
This Electronic Signature Agreement,when finalized and approved, will allow the individuals with
electronic signature credentials to sign electronically a variety of required permit documents in lieu of the
submittal of signed paper copies. The submittal of Electronic Discharge Monitoring Reports(eDMR)
will be available once your electronic signature credentials are in place. Some agreements for document
submittals or acceptance,as noted in the Agreement Conditions(Section B.). are not currently available
electronically but are included here to have the agreements in place and to avoid the need to complete
future submittal of agreement forms when these systems are initiated.
A. Owner/Organization Information
Owner/Organization Name: Mid Century Revitalization,LLC
Responsible Official: Larry Spelts
(as identified in accordance with 40 CFR 122.22)
Street Address: 80 Line Street
City: Charleston
State/Zip: SC 29403
Phone Number: ( 843 ) 518-1786
1 Email Address:
i `email will be the primary method of contact for the electronic [e-mail]
submittal process so it is important to have an accurate email
available at ail times
B. Agreement Conditions
To receive and accept the required electronic signature credential,consisting of a user name and
password. issued by the North Carolina Division of Water Resources(NCDWR) in order to sign
electronic documents submitted to NCDWR's Electronic Document Systems and to receive electronic
documents from NCDWR's systems;
The Responsible Official and Submitter(if applicable)named in this form do herby:
1. Understand that this Electronic Signature Agreement requires me to submit electronic documents to
NCDWR's approved eDMR system under the authorized program in lieu of paper submissions.
2. Understand that this Electronic Signature Agreement requires me to accept electronic transmissions,
in lieu of paper transmissions of all permits,permit modifications,authorizations to construct,and
any other correspondence related to reviewing and processing permits from NCDWR. This
authorization will not become effective until NCDWR establishes a system for processing electronic
documents; I am notified in writing from NCDWR that use of the electronic systems has officially
been initiated;and North Carolina rules and statutes are changed to allow the implementation of
electronic submittal and acceptance of documents.
NCDWR Electronic Submittal Agreement Version 1 Page 1
1

3. Understand that this.Electronic Signature Agreement requires me to submit electronic all necessary
information for processing of NPDES application including information for renewal of existing
permits,modification to existing permits,and applications for new discharge permits.The submittals
may include all necessary applications and supporting documentation to NCDWR's approved system
for electronic submittals in lieu of paper submissions.This authorization will not become effective
until NCDWR establishes a system for processing electronic documents; I am notified in writing from
NCDWR that use of the electronic systems has officially been initiated;and North Carolina rules and
statutes are changed to allow the implementation of electronic submittal and acceptance of
documents.
4. Understand that this Electronic Signature Agreement requires me to accept electronic submissions, in
lieu of paper submissions,of all Notices of Deficiency, Notices of violations,Civil Penalty
Assessments,and any other correspondence related to compliance with federal and state water quality
laws and regulations that might be sent by NCDWR. This authorization will not become effective
until NCDWR establishes a system for processing electronic documents; I am notified in writing from
NCDWR that use of the electronic systems has officially been initiated;and North Carolina rules and
statutes are changed to allow the implementation of electronic submittal and acceptance of
documents.
5. Agree to protect both the electronic signature credential,consisting of my user name and password,
and security questions and answers, from compromise and from use by anyone except me.
Specifically. I agree to maintain the secrecy of my electronic signature credential and security
questions and answers; I will not divulge or delegate my credential or security questions and answers
to any other individual; I will not store my credential or security questions and answers in an
unprotected location;and I will not allow my electronic signature credential or security questions and
answers to be written into computer scripts to achieve automated log-in.
6. Understand and agree that I will be held as legally bound. obligated,and responsible for the use of my
electronic signature as I would be using my hand-written signature.
7. Understand that I will be informed through my registered email address whenever my user name or
password has been modified.
8. Understand that eDMR reports the last date my user name and password were used immediately after
successfully logging into eDMR.
9. Agree to contact the NCDWR eDMR Administrator via email at eUMRidniin a:ncdenr.gov as soon
as possible,but no later than 24 hours,after suspecting or determining that my user name and/or
password have become lost,stolen or otherwise compromised.
10. Agree that I will review the contents of all electronic submissions prior to submission.
11. Understand that I will automatically receive an email receipt at my registered email address from the
NCDWR's eDMR system for any submission that contains a valid electronic signature, identifying
the document received,the signatory.and the date and time of receipt.
12. Agree to contact the NCDWR eDMR Administrator via email at eDR111adminra ncdenr.gov if I do not
receive an email receipt as specified above within five(5) business days for any electronically signed
submission using my credentials.
13. Agree that if I received an email notification for an activity that I do not believe that I performed. I
will notify the NCDWR eDMR Administrator via email at eDMRadminurnedenr.gov as soon as
possible,but no later than 24 hours,after receipt.
NCDWR Electronic Submittal Agreement Version 1 Page 2

14. Agree to report,within 24 hours of discovery,any evidence of discrepancy between any electronic
document I have signed and submitted and what the NCDWR eDMR has received from me by
contacting the NCDWR eDMR Administrator via email at eDMRadmin i ticdenr.2.ov.
15. Understand that the NCDWR eDMR's system will automatically reject any electronic document
submitted without a valid electronic signature if such signature is required.
16. Agree to contact the NCDWR eDMR Administrator via email at el)\-1Radmin ct.ncdenr.sok within
ten working days if my duties change and I no longer need to interact with eDMR on behalf of my
organization.
17. Agree to notify the NCDWR eDMR Administrator via email at el)MRadmirnu;ncdenr.gov if I cease
to represent the regulated entity specified above as signatory'of that organization's electronic
submissions as soon as this change in relationship occurs.
18. Understand that the NCDWR may contact the Organization's Responsible Official,who signs below
to authorize me as a signatory for the Owner/Organization,in order to verify my identity.
19. Agree to retain a copy of this signed agreement as long as I continue to represent the regulated entity
specified above as signatory of the Organization's electronic submissions.
20. Certify that I have the authority to enter into this Agreement on behalf of the Organization identified
above,and I am a signatory authorized to represent that Organization,and I am able to sign and
submit reports and other information on behalf of that Organization in the capacity required by statute
and/or regulation.
C. Permit/Facility Information
Approval under this Electronic Signature Agreement is applicable to the following permits and if
applicable to the Submitters, if noted here and in Section E:
Facility'Name Facility Address Submitter2(if applicable)
fJ Sline MCS(Z t 4 rY1C:��llr�Qr
d1 VI l vattir lki9hkand6PC,
I. You may only include permits associated with Qri(myna. If more space is needed for additional permits or submittcrs you
may attach separate pages. A supplemental sheet is available at:halls:: dcu.nc.eu%°about isiuns-Nater-
resources/cdmr/forms-and-retorts
2. A separate Section E must be included for each Submitter in order to obtain a hard copy signature and notarization for all
entities. If more than one individual will have submitter permissions for the same permit.then indicate this on separate
rows.
NCDWR Electronic Submittal Agreement Version 1 Page 3

D. Responsible Official Signature
The Responsible Official,as identified in accordance with 40 CFR 122.22. is the appropriate individual
with the authority to sign and submit reports for the organization.
1, Larry Spelts (printed name),have the authority to enter into this
Agreement for Mid Century Revitalization,LLC (Owner/Organization Name).
I request the NCDWR grant me and, if included in Sections C and E of this form,the named Submitter(s),
an electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I,and the individual(s)named in Sections C and E(if applicable),work at/for my
organization and have authority to submit and accept electronic documents and act as a signatory for
purposes of the NCDWR's electronic document systems.
NE,By submitting this application, I, Larry Spelts (printed name),have read,
understand,and accept the terms and conditions of this Electronic Signature Agreement. I certify under
penalty of law that I have personally examined and am familiar with the information submitted in this
application and all attachments and that,based on my inquiry of those persons immediately responsible
for obtaining the information contained in the application. I believe that the information is true,accurate
and complete. I am aware that there are significant penalties for submitting false information, including
the possibility of fine and imprisonment.
.4 ti �« ?ce�c t lq 2OLT
Responsib e Official Signature Title Date `
[e-mail] 843-518-1786
Email Address Phone Number
`email will be the primary method of contact for the electronic submittal process so it is important to have an accurate email
available at all times
If you are a current eDMR submitter please provide your User Id:
User Id
Subscribed and sworn to before me this 11 day of 20
(41(vouit
Signature of Notary Public
kitaseN P,• W I I c6NA
Printed Name of Notary Public
My Commission Expires: Of
(SEAL)
NCDWR Electronic Submittal Agreement Version 1 Page 4

i

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G.0201
Permittee Owner/Officer Name: Larry Spelts
Mailing Address: 80 Line Street
City: Charleston State: SC Zip: 29403 - Phone#: [phone]
Email address: [e-mail]
Signature: Date:
Facility Name: SILL3iihe L 4-vfl 1 tact wu `rP Permit#: NIL( L)36( L
County: Manx,
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
iologicai) Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge(ORrC,)� 1
Print Full Name:POI/I Q)( 5 1'UrMer Email:AY"QVIS,e ( fttt-(m
4
Certificate Type/ e/Number: — Work Phone#: O :?C►rGGD'
Signature: Date: ` - `-- as
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted.I understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G.0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission.-
Back-Up Operator in Responsible Charge(BU ORC) �`t
Print Full Name:�IT Q ? Email: AI,L1U\ \%%ig()trct4.am
Certificate Type/Grade i ber: Work Phone#: tat- ,Q
Signature: * L— Date: r \' aa
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted.I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmin(a.ncdenr.Qov
Mail or fax a£ Pi to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 F.Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W. Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Revised 05-2015

WPCSOCC Operator Designation Form, cont.
Facility Name: W5\V\Q,1---t + V (t�G WIA l P Permit#: Do 564.a
Back-Up Operator in Responsible Charge(BU ORC) (� 1_ ,� -L'^ �w
Print Full Name: kl t`j1-irt R5h'1-CY . Email: Qbt'1�J[W "Td-J�` 1 Gti I•C. 1
Certificate Type/Grade/Number: WW1" 1001551 Work Phone#: 'ig'JCQ-C
Signature: atab, 4L4w,CeA Date: L\-\
"I certify'that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted.I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in I5A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.-
Back-Up Operator in Responsible Charge(BU ORC)
Print Full Name: PaVa arC.L.13 W l Kam^ Email: Q!„1�/1kQ �q�Y�tct �
Certificate Type ade/Number: 1&IW a&" Low) Work Phone G
vim►S fj�.o—y�.i wp
Signature: Date: `-V ,'C�►�►
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in I5A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.-
Back-Up Operator in,,Responsible Charge(BU ORC)
Mark_
Print Full Name: 1" kX k JI U . Email:Prvifto Y atnc a ab1•c(W
Certificate Type!Grade 'Numb : • - toga() Work Phone#:
Signature: Date: Lk-k-
1
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted.I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in I5A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.-
Back-Up Operator in-Responsible Charge(BU ORC)
T `� 1
Print Full Name:_ AIL _w( Kt_ Email: d�UV 11�CLY a.I .
Certificate Type/ de/Number: W W 3 - QgL0DI2.Work Phone J�kP-i3
Signature: ‘t/l/L_ Date: Lk-A- Wv►
•1 certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted.I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 05-2015

EXHIBIT A
Deed of Trust
Mid Century Revitalization, LLC
to
Skyline Lodge & Restaurant, Inc
TRACT I: (portion of Parcel # 7540-09-0697)
BEING all of that 3.03 acre parcel as shown on a plat prepared by
Aaron Garrett Land Surveying, P.C., dated January 9, 2020, and
recorded at Plat Book 5, Card 11066, Macon County Registry, reference
to which is made for a more complete description thereof.
EXCEPTING and RESERVING to the Grantor from said parcel a
perpetual easement 10 feet in width over and across the same in the
present location of the existing septic system connector lines leading from
the "Courtside Cottages" on Grantor's retained lands (a portion of the
referenced tax parcel lying generally north of the conveyed parcel) to the
point of connection with the sewage treatment system located on the
ground level of the building depicted on the above-referenced plat,
together with the right to inspect maintain, repair and replace said
connector lines. the sewage conveyed thereby shall be treated by Grantee
at no cost to the Grantor.
SUBJECT TO an Easement ten feet (10') in width for existing
water lines connecting the building and improvements on the conveyed
3.03 acre parcel to the well and water distribution system owned and
operated by Grantor which serves as the sole source of water supply for
the structure and improvements located on the conveyed 3.03 acre parcel.
Grantor and Grantee have entered into a separate Agreement this date
which obligates Grantor its successors and assigns as owners of the well
and water distribution system to supply water to the 3.03 acre parcel. As
a part of this Agreement, the Association is obligated to maintain and
repair these water lines.
TOGETHER WITH an Easement twenty feet (20') in width
for the existing underground sewage transmission lines in their present
location leading from the sewage treatment facility under the structure
on the above conveyed 3.03 acre parcel across that 40 foot (40') easement
identified as "Lodge Drive" and "Laurel. Falls Drive" on the plat recorded

at Card 1546, Macon County to the below-conveyed "Tract Three",
together with the right to inspect, maintain repair and replace said lines.
SUBJECT TO Grantor's retained joint right to the use of all right
of way Easements depicted on the above-referenced plat.
TRACT TWO: A view easement over and across Grantor's retained lands
described as Lot 31, Laurel Falls, lying Southwesterly of the above
described 3.03 acre parcel, for the benefit of said 3.03 acre parcel, which
shall include the right to cut and trim trees and vegetation from time to
time at Grantee's sole discretion without the necessity of obtaining
permission from Grantor or the Architectural control committee of Laurel
Falls at Skyline.
TRACT THREE: (portion of Parcel# 7530-99-6309)
BEING all of that 0.65 acre parcel as shown on a plat prepared by
Aaron Garrett Land surveying, P.C. recorded at Plat Book 5, Card 11065,
Macon County Registry to which reference is made for a more complete
description thereof.
EXCEPTING and RESERVING to the Grantor an easement upon
that portion of the 0.65 acre parcel lying westerly of the "Sewer Filter
Area" shown thereof an easement for existing and future septic tanks,
drainfields, connector lines, pumps and other sewage treatment
equipment in such location as they presently exist or in the future as
they may be located at Grantor's discretion, for the benefit only of the
adjoining Lot 16, Laurel Falls at Skyline, together with the right to
inspect, maintain, repair and replace such facilities and to relocate the
same and to install new facilities in locations selected by Grantor with
the sole limitation that such lines as existing or located in the future shall
not interfere with or prevent with the transmission of sewage from the
"Sewer Filter Area" as shown on the plat to a water source as permitted
by the NCDHEC permit allowing its operation and maintenance.
TRACT FOUR: A perpetual easement for the benefit of Tracts One and
Three above, jointly and in common with Grantor and all others entitled
to the use thereof, over and across all private roadways leading from Flat
Mountain Road (NCSR ***) to the above described Tracts One and Three
for the purpose if ingress and egress. This Easement shall run in favor
of Grantee, its agents, employees, invitees and guests. Although grantee

is not a member of the Laurel Falls Owners Association, Grantee agrees
to pay a reasonable, proportionate share of the cost of maintenance and
upkeep of said easements.
TRACT FIVE: An Easement for parking as shown on the plat referred
to in Tract One above recorded at Book 5 Card 11066, Macon County
Registry identified thereon as "Paved Parking Lot", a 0.12 acre parcel,
lying on Lot 31 Laurel Falls at Skyline.
TRACT SIX: That specific Easement reserved by Grantor in the
Declaration of Protective Covenants for Laurel Falls as recorded at Book
0-20, Page 767, Article IV, Section 11, Macon County Registry for the
sign located at the intersection of Flat Mountain Road and Skyline Drive
Y
which is located on common property of Laurel Falls Association,
together with the right of access to said sign and the right to inspect,
maintain, repair and replace the same.
THIS IS A PURCHASE MONEY DEED OF TRUST

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