NCC240794_FRO Submitted_20240326

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.
r �
1. Project Name j-/ )1Id
�
2. Location of land-disturbing activity: County "a►c7' City or Township_&/ M.1///
cam,$ 1'C� f
Highway/Street4 ii 1 j/j(J O'' ��`c1j Latitude(decimal degrees),?S 9O h ( Longitude(decimal degrees)d�j Z. S
3. Approximate date land-disturbing activity will commence: 7'`/yt4 Z 7, 20 Z
4. Purpose of development (residential, commercial, industrial, institutional, etc.): . 0S/dl5414a,
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
pv�'aJ;v�ct( 0(Z cP d ��n
6. Amount of fee enclosed: $ vital ��3rl
&too -f-c al 'ile 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 p No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Nam e,Lpi S rqf E-mail Address J('S gkCeregmq// ur,
Phone: Office# Mobile# gZ r^778r -qz yy
9. Landowner(s) of Record (attach accompanied page to list additional owners):
-4rr1 /� s 710 -2s7-g�3, /
Name Phone: Office# Mobile#
1 fir,!2- k 112- S- ,
Current cling Address Current Str t Address
Nulty SPri9 c /I/C. Z?syo ti 6 �'p ,vc
City State Zip C / `7T State Zip
10. Deed Book No. W$3 Page No. -7 0 t Provide a copy of the most current deed.
RECEIVED
LAW'064 A 116b12,1 10:
to4vfirk" ' i_

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) f of
the"owner(s)may be listed as the financially responsible party(ies).
s7AwLidn;... 01-.417
/11-1 Z-S-40117*gr7OVI4 afr"
ompany Na a E-mail Address
,6,0at pc, ay
tlit
4'Cu rent a n Address Current titre ddress
9
l� Sp11Zn917(kryi� ZiPy
Phone: Office# Mobile# Aftelialer7
4?140 -- ZS7—S33Sc
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
RECEIVED
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company) LAND Eiblitt I 1 ak.eu u0:

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# RECEIVED
ED
LAND(N C 1 t SEC'ICE►'
'A,t !It:

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.`I
RE tVED
Landowner 5 of Record:
Name Phone: Office# Mobile4AND'ARt-t t T JhI,1 JO'
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.

(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 thee information provided herein.
l
Type or rint ame Title or Authority
_ CeS/Ze.,1:3
Si a Da 7
I, 6\'I A P X1 i J r�S1 , a Notary Public of the County of l/l)11 Y`t
State of North Carolina, hereby certify that \.Y 1I1 1/)f pf �� �}/\� appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this hi-i-hday of U n , 20 •;./2
.9 f44JZ / W
i q9�: Notary c MArV -KAT() HA•
VP*- o / My commission expires 5 1 a,31
� coeLlG •G /
RECEIVED
i..AND!AC( St.0 TiOF''

Addendum to FR/O form Part A, Item 9: Landowner of Record Letter of Consent
Landowner of Record Name: ?enMains
S
Property Tax ID#/PIN: 0000S21--14,
Property Address Line 1: 6 S 1—(=( l( _ 1N4KOOLOS
Property Address Line 2: t �p-7 (�
City/State/Zip Code: �L� I G 0 / l
Applicant submitting plan - must match the financially responsible party named in Part B
Section 1 of the Financial Responsibility/Ownership (FR/0) Form:
()0.00VG
17
Statement of Landowner Consent: In accordance with NCGS 113A-54.1(a), I hereby declare
that I am the owner or legally authorized representative of the owner of the property described
above and provide my consent for the applicant cited above and in Part B of the FR/0 form to
submit a draft erosion control plan to the State of North Carolina and to conduct the planned
land-disturbing activities on the property listed above and in Part A of the FR/O form.
`ynType or Print Na Title or Authority
i
1 _ � v
Signature J Date
T(7 "a*
m to? 1 S
Email Telephone
L v
REGEIVED
LAND Ali>1.A1 t

BK: CRP 883
PG:701 -703 NC FEE526.00
DEED 202200251T STATE OF NC
RECORDED' YANCEY COUNTY,NC REAL ESTATE
08/12/2022 SUSAN JOBE
12:44:08 PM REGISTER OF DEEDS
EXTX S467.00
Total Pages:3 TOTAL S493.00
PREPARED BY: Dale W.Hensley,a licensed North Carolina Attorney,P.O.Box 1570,Burnsville,NC 28714
Delinquent Taxes, if any,to be paid by closing attorney to the County Tax Collector upon disbursement of closing
proceeds.
The property herein conveyed does include the primary residence of a Grantor.
Parcel ID:a portion of 074901382785000
Revenue Stamps:$467.00 Index:Lots 10-16&19-25 Highland Meadow Ridge
And.754 acre(Green Space)Crabtree Twsp.
NORTH CAROLINA
YANCEY COUNTY GENERAL WARRANTY DEED
THIS DEED made this the 1 I day of Acts USi" , 2022, by ABRA REMILLARD,
Widow, (57 Pinnacle Drive, Burnsville, NC 28714) Grantor, to PERRY A.
it
Springs,NC Grantee. A�
SkybrookIVErJ
Drive,Holly 27540),
LAND LIWIt_U t otL1
WITNESSETH: SO?;
THAT the said Grantor,for the sum of TEN DOLLARS(S 10.00)and other good and valuable
consideration, the receipt of which is hereby acknowledged, has and by these presents does convey
to the said Grantee, as tenants by the entirety,his or her heirs and assigns, a certain tract or parcel of
land located in the Crabtree Township, Yancey County, North Carolina, and more particularly
described as follows:
See Exhibit A attached hereto and incorporated herein by reference.
Submitted electronically by "Dale w. Hensley, Attorney"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Yancey County Register of Deeds.
DALE W. HENSLEY,ATTORNEY AT LAW, PO BOX 1570,BURNSVILLE,NC 28714

TO HAVE AND TO HOLD the aforesaid tract or parcel of land and all privileges and
appurtenances thereto belonging to the said Grantee, as tenants by the entirety, his or her heirs and
assigns, in fee simple forever.
And the said Grantor covenants with said Grantee that Grantor is seized of said premises in
fee simple and has the right to convey in fee simple; that the same is free and clear from all
encumbrances, and that Grantor does hereby warrant and will forever defend the title to the same
against the claims of all persons whomsoever.
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.
IN WITNESS WHEREOF,the Grantor has hereunto set his hand and seal,the day and year
first above written.
(SEAL)
ABRA REMILLARD
RECEIVED
STATE OF NORTH CAROLINA LAND Cllrlt.l I T 6Leii0'
tvati
COUNTY OF YANCEY ,. aFr
1, a-n nc.44c M ne5 , a Notary Public in and for the State and County
aforesaid do hereby certify that, ABRA REMILLARD personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and Notarial Seal, this the I l day of P u OUS+ , 2022.
4w}krn rCLOW3
ANNETTE M. NUNES Notary Public
Notary Public
Yancey County, NC My commission expires:Ejan-e 25 E 202
My Commission Expires b-zs-=7-
DALE W. HENSLEY, ATTORNEY AT LAW, PO BOX 1570, BURNSVILLE, NC 28714