NCC241564_FRO Submitted_20240522

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 NCG01 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 NameThe Lake at Lissara Lots 125, 126, 127
"If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Forsyth City or Township Lewisville
355,361,367 Lissara Lodge Dr 36.1048 -80.4465
Highway/Street Latltude(decimal degrees) LongltUde(decimal degrees)
3. Approximate date land-disturbing activity will commence:5/28/20
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.11
6. Amount of fee enclosed: $300.00 . 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 El Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameAlex Mitchell E-mail Address [e-mail]
Phone: Office# 336-409-0226 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Third Generation Homes LLC 336-409-0226 336-782-8268
Name Phone: Office# Mobile#
2625 Neudorf Rd. STE 700 2625 Neudorf Rd. STE 700
Current Mailing Address Current Street Address
Clemmons , NC, 27012 Clemmons, NC, 27012
City State Zip City State Zip
Page No.2901
10. Deed Book No.3805 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).
Third Generation Homes LLC [e-mail]
Company Name E-mail Address
2625 Neudorf Rd. STE 700 2625 Neudorf Rd. STE 700
Current Mailing Address Current Street Address
Clemmons, NC, 27012 Clemmons, NC, 27012
City State Zip City State Zip
Phone: Office#336-409-0226 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:
NA NA
Name of Registered Agent E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office# NA Mobile# NA
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:
NA NA
Name of Registered Agent E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office# NA Mobile# NA
NA
Name of Individual to Contact(if Registered Agent is a company)

(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.
NA
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.
Alex Mitchell Construction Superintendent
T pe or print name Title or Authority
i ii& Ui/J l-G )--I 5/20/20
Signature Date
I, e'\o-e v\e-`\ , a Notary Public of the County ofA\Q
State of North Carolina, hereby certify that P\\tX \N v\--c)11-L,k 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 20 day of K61 , 20 19
REBEKAH MITCHELL 12,62 Vkl-r/CA/d
Notary Public,North Carolina Notary
Davie County My Commission Expires My commission expires Mal n��dv 26 t 2 O Z1
May 26,2027

2024014790 00070
FORSYTH COUNTY NC FEE$26.00
STATE OF NC REAL ESTATE EXTX
$260.00
PRESENTED& RECORDED
05/09/2024 11:40:09 AM
LYNNE JOHNSON
REGISTER OF DEEDS
BY: CHELSEA B MARTINEZ, DPTY
BK: RE 3805
PG: 2901 -2903
Excise tax paid: 24.c' e> `' Parcel identifier No.
Mail after recording to/future tax bills to: Grantee C C' .Ste. 7 o c'
This instrument prepared by: James W. Armentrout (no title search requested or performed)
FORSYTH COUNTY, NORTH CAROLINA GENERAL WARRANTY DEED
This DEED made this 1st day of may , 2024 by and between
GRANTOR GRANTEE
LISSARA LAND, LLC THIRD GENERATION HOMES, T.LC, a NC
A NC limited liability company limited liability company
P.O. Box 10, Bethania, NC 27010 Lissara Lodge Drive
Lewisville, NC 27023
THIS PROPERTY DOES NOT INCLUDE THE PRIMARY RESIDENCE OF A GRANTOR.
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 and
sufficiency of which is hereby acknowledged, has and by these presents does grant, bargain, sell and
convey unto the GRANTEE, its heirs, successors and assigns, in fee simple, all that certain lot or parcel of
land situated in Lewisville Township, Forsyth County, North Carolina, and more particularly described as
follows:
ATTACHMENT A HERETO
Submitted electronically by "Fleming & Williams, LLP"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Forsyth County Register of Deeds.

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 forever. 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 subject to the following exceptions: ad valorem
taxes hereinafter becoming due and payable; restrictive covenants, and easements and rights-of-way of
record, if any.
IN WITNESS WHEREOF,the undersigned Limited Liability Company GRANTOR has caused this instrument
to be signed in its company name by its duly authorized Manager, and has adopted the word "SEAL"
appearing at or beside its name and the signature,this the 1St day of Nay , 2024 .
LISSARA LAND, LLC
- ,
t
By: "- . - ---- -. (SEAL)_ _
C.J. Ramey Manager
North Carolina—Forsyth County
I certify that the following person personally appeared before me this day, that I have personal
knowledge of the identity of said person,and that he acknowledged to me that he signed the foregoing
document: C..1, Ramey , Manager of LISSARA LAND, LLC,
GRANTOR.
Date: 5-1-2QlitTles W Armentr0Ut
NOTARY PUBLIC I
Notary Public
Forsyth County,NC
My Commission Expires March 25,2027 James W. Armentrout
Print Name
My commission expires: 3-25-2027

EXHIBIT A
BEING KNOWN AND DESIGNATED as Lot 125 as shown on the Plat of Survey entitled
"The Lake at Lissara, Phase 2,Section VII"as recorded in Plat Book 79, Page 88, Forsyth County, North
Carolina Registry,reference being thereto for a more particular description.
Subject to the Declaration of Covenants, Conditions and Restrictions recorded in Book 2959, Page 1949,
Forsyth County, North Carolina Registry. Also subject to the Annexation document recorded in
Book 3802,Page 3353, Forsyth County, North Carolina Registry.

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