NCC231667_FRO Submitted_20230612

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Name Riverbend Lot 61
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
654 River Bend Driver Granite Falls, NC 58630
2. Location of land-disturbing activity: County Caldwell City or Township Granite Falls
Riverbend Drive 35 . 7860 —81 . 3848
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 1/15/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): '35
6. Amount of fee enclosed: $ 100 . 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 E Enclosed 0 No E
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tommy Blanton E-mail Address [e-mail]
Phone: office# 828-310-0441 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Mark Godfrey
Name Phone: Office# Mobile#
1514 12TH ST DR NW 1514 12TH ST DR NW
Current Mailing Address Current Street Address
Hickory, NC 28601 Hickory, NC 28601
City State Zip City State Zip
10. Deed Book No. 2038 Page No. 610 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).
Jarred Thomas Company, LLC. [e-mail]
Company Name E-mail Address
1062 2Oth Ave. Lane NW 1062 2Oth Ave. Lane NW
Current Mailing Address Current Street Address
Hickory, NC 28601 Hickory, NC 28601
City State Zip City State Zip
Phone: Office# 828-310-0441 Mobile# [phone]
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:
Thomas L. Blanton jarredthomascompany@gmail . com
Name of Registered Agent E-mail Address
1062 20th Ave Lane NW 1062 20th Ave Lane NW
Current Mailing Address Current Street Address
Hickory, NC 28601 Hickory, NC 28601
City State Zip City State Zip
Phone: Office# Mobile# 8 2 8—310—0 4 41
Thomas Blanton
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 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:
Stephanie Queen
Name Phone: Office# Mobile#
1514 12TH ST DR NW 1514 12TH ST DR NW
Current Mailing Address Current Street Address
Hickory, NC 28601 Hickory, NC 28601
City State Zip City State Zip
Deed Book No. 2038 Page No. 610
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.

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#

BK 2038 PG 610 - 612 (3) DOC# 10064486
This Document eRecorded : 10/27/2021 12 : 28: 40 PM
Fee: $26. 00 Tax: $76. 00
Caldwell County, North Carolina
Wayne L. Rash , Register of Deeds
NORTH C . ;.. ()LINA ' ENE .... 's „k:.. TY DEED
Excise Tax: $76M0 Parcel Identifier No.: 2794295387
This instrument was prepared by: Fleischer Law Office, PLLC, 7 14th Street SW, Suite 100, Hickory, NC 28602
Brief Description from the Index: Lot 61 of River Bend, Phase I, Section C, Plat Book 18, Page 247
THIS DEED made this 27th day of October, 2021, by and between
GRANTOR , R .:::.. .'.TEE
Phillip Emerson Cubbage and Kristen Leigh Cubbage, Mark Godfrey and Stephanie Queen, husband and wife
husband and wife
1514 12th Street Drive Northwest
152 Gunpowder View Circle Hickory, NC 28601
Granite Falls, NC 28630
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.
WITNES SETH, 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 Lovelady Township, City of Granite Falls, Caldwell County, North Carolina
and more particularly described as follows:
See Exhibit "A" Attached Hereto and Made a Part Hereof
The property herein described r l is or ' �` .s not the primary residence of the Grantors.
The property herein described was acquired by Grantor by instrument recorded in Book 1980, Page 392, Caldwell
County Registry.
A map showing the above described property is recorded in Plat Book 18, Page 247, and referenced within this
instrument.
submitted electronically by " Fleischer Law office , PLLC"
' in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Caldwell County Register of Deeds .

BK 2038 PG 611 DOC# 10064486
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 except for the exceptions hereinafter
stated.
IN WITNESS WHEREOF, the Grantor has hereunto set his hand, or if corporate, has caused this to be signed in its
corporate name by its duly authorized officers by authority of its Board of Directors, the day and year first above
written.
P f Emers• : t ge
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'stew Leigh Cubbage
STATE OF NORTH CAROLINA
COUNTY OF CATAWBA
I, the undersigned, Notary Public, do hereby certify that Phillip Emerson Cubbage and Kristen Leigh Cubbage
personally appeared before me this day and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this 27th day of October, 2021 .
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Official Signature of Notary %‘‘ Ge r0J.:ee
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Printed or type ame of Notary �.
My Commission Expires: 3 ) 11 iic) •• c) :1 ':
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NC Bat Association Form No. 3 D 1976, Revised 0 111l2U 1 0
Printed by Agreement with the NC Bar Association

BK 2038 PG 612 DOC# 10064486
Exhibit "A"
BEING all of Lot 61 of River Bend, Phase 1, Section C, as shown on plat recorded in Plat Book 18, Page 247,
Caldwell County Registry, North Carolina, reference to which is made for a more particular description.
But this conveyance is made subject to the terms, provisions, covenants, conditions, easement and restrictions set
forth in the Master Declaration of Covenants, Conditions and Restrictions for River Bend of Lake Hickory dated
January 15, 1999 and recorded in Book 1249, Page 752 of the Caldwell County Registry; the First Supplementary
Declaration of Covenants, Conditions and Restrictions for River Bend Club Pointe, Phase I, Section C and Phase 1,
Project B, Section 1 , Part B recorded in Book 1291,, Page 246, Caldwell County Registry; and the First Amendment
to First Supplementary Declaration of Covenants, Conditions and Restrictions for River Bend Club Pointe, Phase I,
Section C and Phase I, Project B, Section 1 , Part B recorded in Book 1329, Page 1276, Caldwell County Registry.
Tax Parcel Number: 2794295387
Property Address: Vacant Lot, Granite Falls, NC 28630
NC Bar Association Form No, 3 7 1976, Revised 0 1/1/2010
Printed by Agreement with the NC Bar Association