NCC232035_FRO Submitted_20230705

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 Mossy Ridge MH Park
`If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name of Project
Number(e.g. SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DEN',
2. Location of land-disturbing activity: County Jackson City or Township Glenville
Highway/Street Mossy Ridge Road Latitude{decamaldegreesr35.189 Longitude�de�,ma degrees) -83.175
3. Approximate date land-disturbing activity will commence: 7/1/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Comm/Res
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 4.59
6. Amount of fee enclosed: $ 1 00.00 . 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Lehotsky E-mail [e-mail]
Phone: Office# 828-743-5864 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
West Rock Investments, LLC 828-743-5864 828-371-1218
Name Phone: Office# Mobile#
P. O. Box 3291 87 Chestnut Square
Current Mailing Address Current Street Address
Cashiers NC 28717 Cashiers NC 28717
City State Zip City State Zip
2234 1886
10. Deed Book No. Page No. 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).
West Rock Investments LLC [e-mail]
Company Name E-mail Address
PO Box 3291 87 Chestnut Square
Current Mailing Address Current Street Address
Cashiers NC 28717 Cashiers NC 28717
City State Zip City State Zip
Phone: Office# 828-743-5864 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:
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)
(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)

(c) lithe 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.
John Lehotsky Owner
Type or prin Title or Authority
6/28/23
Signature Date
I, \it t1 i l 1� Y K K . Le V?,$lf 1AL, , a Notary Public of the County of M. O41.o 11
State of North Carolina, hereby certify that J o h i l Le 1,1 a S L appeared personally
before me this day and being duly sworn acknowledged that the above rm was executed by him/her.
Witness my hand and notarial seal, this '?"day of J UAL , 20 iil C'dk.✓
JENNIFER K LEVESQUE Notary
V G
NOTARY PUBUC
MACONNORTH C OUNT W My commission expires I I-�- a0 :71 7
My Commission Expires I t-S-Ao 4-7

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:
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 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#

Page 1 of 3
Doc ID 005699030003 TYpe: WARRANTY
reeoAmta $81 00 PaoeaI of 3� 01 Pt!
Jackson Count$. to
Joe Hamilton Reoister of Oeeds
BK2234 PG1886-1888
��yvoce . 1
93"
r =
vac/ON O
This instrument prepared by Kimberly R.Coward of Coward,Hicks&Siler,P.A.,
Post Office Box 1918,Cashiers,NC 28717,a licensed North Carolina attorney.
Delinquent taxes,if any,to be paid by the closing attorney to the county tax collector upon
disbursement of closing proceeds.
Rev.$155.00;unimproved;not primary residence
PIN:7554-29-5705;whole transfer
STATE OF NORTH CAROLINA
COUNTY OF JACKSON
WARRANTY DEED
THIS WARRANTY DEED is made this 9th day of April,2019,by and between ISAAC
MOSS a/k/a William Isaac Moss,of 25 Rose Hill Drive,Franklin,NC 28734,hereinafter
referred to as"Grantor,"joined by his spouse,JAMES DAVID TAYLOR,for the Imited
purpose set forth hereinbelow,and WEST ROCK INVESTMENTS,LLC,a North Carolina
limited liability company,of PO Box 3291,Cashiers,NC 28717,hereinafter referred to as
"Grantee." The terms grantor and grantee shall be used as neuter singular designation of the
parties hereto,their personal representatives,heirs,successors and assigns.
W ITNESSETH:
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 Mountain Township,
Jackson County,North Carolina,and more particularly described as follows:
BEING ALL of Tract 3,containing 0.02 acre and Tract 6,containing 6.2 acres,as shown
on a plat thereof prepared by Clark Lipkin,PLS,dated September 14,2007,last revised
October 8,2007 and recorded in Plat Cabinet 16,Slide 991,Jackson County Registry,to
which reference is specifically made.
(4)
Book: 2234 Page: 1886 Seq 1

Page 2 of 3
ALSO BEING those certain parcels of land allotted to the Grantor herein by Report of
Commissioners recorded in Book 1713,Page 518 and confirmed by Order of
Confirmation recorded in Book 1713,Page 521,Jackson County Registry,to which
reference is specifically made.
TOGETHER WITH rights and SUBJECT TO the easement,restrictions,reservations and
exceptions as set forth on the above-referenced Report and Order.
TOGETHER WITH a non-exclusive right-of-way,thirty(30)feet in width,over the
existing access road and easement designated"Private Soil Road"and"Private Road
Proposed 30'R/W"on the above-referenced plat for purposes of ingress and egress
between subject property and NCSR 1145(Pine Creek Road),as said rights-of-way are
given in the above-referenced Report and Order.
SUBJECT TO the rights-of-way of the access road and soil road shown on the above-
referenced plat.
SUBJECT TO utility easements of public record.
Pursuant to the provisions of N.C.G.S.§29-30(a)(1),James David Taylor joins in this
conveyance for the sole purpose of releasing and quitclaiming his marital rights in the
property herein described,as said rights are defined in N.C.G.S.§29-30(a).
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,subject to the reservations,
exceptions and limitations contained herein_
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.
Title to the property hereinabove described is conveyed subject to the following
exceptions:
Exceptions and reservations contained in this deed and/or in instruments referenced
herein.
Easements and rights-of-way for public and private roads and utilities,of public record.
Lien of ad valorem taxes for the current year and subsequent years,not yet due and
payable.
2
Book: 2234 Page: 1886 Seq_2

Page 3 of 3 W_
IN WITNESS WHEREOF,the Grantor has hereunto set its hand and seal the day and
year first above-written.
(j/k/-vr---4/41- 4-- (SEAL) �- ' (SEAL)
ISAAC MOSS a/k/a WILLIAM ISAAC MOSS S DAVID TAYLOrR
STATE OF Jt r'` 1. 6G f //rt4,
COUNTY OF
I,a Notary Public of /ii-e r -' County and the State aforesaid,certify that
the following person(s)personally appeared before me this day,each acknowledging to
me that he or she signed the foregoing document:ISAAC MOSS a/k/a WILLIAM ISAAC
MOSS.
DATE: 80 Z��y
(OFFICIAL EAL)
___7<(14/‘ /Y•-
Notary Pc
KAREN LANG PETERSON
NOTARY PUBLIC K r a� i f-�0y1
MACON COUNTY,NC ��, UUU
(Printed Nam of Notary)
My Commission Expires: 91,e41..e.14 - i`t
STATE OF ilo ll[MA:ea—
COUNTY OF Mat y1
I,a Notary Public of JCAp,�,ar, County and the State aforesaid,certify that
the following person(s)personally appeared before me this day,each acknowledging to
me that he or she signed the foregoing document: JAMES DAVID TAYLOR.
DATE: , d` aQv 9
11;04 z ,,.zp
(OFFICIAL EAL)
Notat ublic
1 /'`P S-dYl
` - - (Printed Namd/of Notary)
My
KAR
NOTARY PUMA
MACON COUNTY,NC
14-0i i/wd
3
Book: 2234 Page: 1886 Seq:3