NCC223742_FRO Submitted_20221103

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 address
or phone number is unavailable, place N/A in the blank.)
Part A.
1. Project Na
Trait Ridge Phase 1 — 8 Lots
Forsvth Kernersvilie
2. Location of land -disturbing activity: County City or Township
County Line Rd.
Highway/Street SR1307 Latitude(decimaidegrees) 35.1343 Longitude(decimaidegrees)80.0403
3. Approximate date land -disturbing activity will commence: October 15 2022
residential
4
5
Purpose of development (residential, commercial, industrial, institutional, etc.):
4.0
Total acreage disturbed or uncovered (including off -site borrow and waste areas):_
400.00
5. Amount of fee enclosed: 5 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling 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 ❑ Enclosed IM No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
X Scott Smith [e-mail]
Name
336-802-1340
Phone: Office #
E-mail Address
Mobile #
336-508-1410
9. Landowner(s) of Record (attach accompanied page to list additional owners):
H&H Constructors Of Fayetteville, LLC 336-802-1340
Name
2411 Robeson St Ste 200
Current Mailing Address
Fayetteville NC
Phone: Office # Mobile #
2411 Robeson St Ste 200
Current Street Address
28305 Fayetteville NC 28305
City State Zip City
3713 3952
10. Deed Book No. Page No.
State
Zip
Provide a copy of the most current deed.

(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.
I;rntt Smith
Type or print name
Signature
b
Title or Authority
712
Date
I, a Notary Public of the County of-_Y'
State of 41-i Carolina, hereby certify that Y-" A-q, appeared
personally before me this day and being duty sworn acknowledged that the above form was
executed by him/her.
Witness my hand and notarial seal, this day of V _— ZO .
- CXN -
Notary
Seat
_ My commission expires ;k —
MANDY F SCOTT F
NOTARY PUBLIC
GUILFORD COUNTY, NC -
MY COMMISSION EXPIRES

Continued from Items 9 & 90 in Part A of the Financial ResponsibilitytOwnership 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
Current Mailing Address
City State
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
City State
Deed Book No,
Phone: Office #
Current Street Address
Mobile #
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone; Office #
Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.

_ M
Continued from Item 9 in Part B of the Financial ResponsibilitylOwnership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible patties.
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
Current Mailing Address
City
Phone
E-mail Address
Current Street Address
State Zip City
Office #
State Zip
Mobile #

2022039152 00209
FORSYTH COUNTY NC FEE $26.00
STATE OF NC REAL ESTATE EXTX
$1296.00
PRESENTED & RECORDED
08/2212022 03:56:29 PM
LYNNE JOHNSON
REGISTER OF DEEDS
BY: ANGELA M THOMPSON, DPTY
BK: RE 3713
PG: 3952 - 3953
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: S 1,296.00
Parcel Identifier No. Verified by County on the day of , 20
By:
Mail/Box to: Grantee: 7200 Falls of the Meuse Road Suite 202 Raleigh. NC 27615
This instrument was prepared by: Anthony P. Donato. Attorney at La1v (without title examination)
Brief description for the Index: Lot Nos. l -6. 34 & 35 Trail Ridge, Ph I
THIS DEED made this 19th day of August, 2022, by and between
GRANTOR
Generation Development Company, LLC,
a North Carolina limited liability company
Nfailing Address:
5932 Tarleton Drive
Oak Ridge, NC 27310
GRANTEE
II&H Constructors of Fayetteville, LLC,
a North Carolina limited liability company
Property Addresses:
Lots 1-6, 33 & 35, Elk Court
Kernersville, NC 27284
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 near the City of Kernersville , Forsyth County, North Carolina and snore
particularly described as follows:
BEING ALL OF LOTS 1, 2, 3, 4, 5, 6, 34, & 35, TRAIL RIDGE -PHASE ONE, AS PER PLAT THEREOF
RECORDER IN PLAT BOOK 76, PAGE 44, FORSYT14 COUNTY REGISTRY, NORTH CAROLINA.
The property hereinabove described was acquired by Grantor by instrument recorded in Book 36 33 page 2672.
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 76 page 44.
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 title against the lawful claims of all persons whomsoever, other than the following exceptions!
All easements, rights -of -way, and restrictions of record upon the described property, and to ad valorem taxes for the current
year.
written.
IN WITNESS WffEREdp, the Grantor has duly executed the foregoing as of the day and year first above
Generation Development Company, LLC
S( EAL?
Print;Type Name. Marls Smith
Managing Member
State of North Carolina County of Guilford
1, the undersigned Notary Public of the County of Guilford and State aforesaid, certify that Mark
Smith, Managing Member of Generation Development Company, LLC personally appeared before me this clay and
acknowledged the due execution of the foregoing instrument for the purposes therein expressed. Witness my hand and
Notarial stamp or seal this 19th day of August, 2022.
My Commission Expires: 03i25/23
(Affix Seal)
Anthony P. Donato Notary Public

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83 Security features. Details on back.
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