NCC241611_FRO Submitted_20240528

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Name RELO Monroe Chick-fil-A
2. Location of land-disturbing activity: County_Union City or Township Monroe
Highway/Street 2579 W Roosevelt Blvd Latitude(decimal degrees)_35.0148_Longitude(decimal degrees)_-80.5717
3. Approximate date land-disturbing activity will commence:_June 3, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Restaurant
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_3.1
6. Amount of fee enclosed _$1,400 . The Express Permitting application fee is a dual
charge. The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which
the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is
$2,900). Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameR. Todd Williams E-mail [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Ty-Par Realty, Inc. _(704-238-9700
Name Phone: Office# Mobile#
_2593 W Roosevelt Blvd
Current Mailing Address Current Street Address
_Monroe NC 28110
City State Zip City State Zip
10. Deed Book No. 863 Page No._701 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).
_Chick-fil-A [e-mail]
Company Name E-mail Address
_5200 Buffington Rd
Current Mailing Address Current Street Address
_Atlanta GA 30349
City State Zip City State Zip
Phone: Office# 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:
_Will Whitley [e-mail]
Name of Registered Agent E-mail Address
1518 E. Third St., Suite 300
Current Mailing Address Current Street Address
Charlotte NC 28204
City State Zip City State Zip
Phone: Office# Mobile# [phone]
_Will Whitley
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) 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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering firm or other consultant E-mail Address
Individual contact person (type or print) Phone: Office# Mobile#
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.
1.1D'D WAuU °v P'REC1'b'R
Type or int name Title or Authority
P - AFL 24L 2o2m
Signat re Date
I, %?GPI( a. , a Notary Public of the County of QGont.-e
State of No hGCa (retina', hereby certify that °°« 6V;< <i 4.if..s 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 27� day of 40,-. 1 , 20 7--1
IA54PMeKA' VCen" ma /( .ary Pu , ia
4 Ze/te.
-.d--;•c Oconee County
-4R,:A ,' My Commission Expires Notary
i/ignit s February 18. 2026
sear My commission expires Z/f&/Z S

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Recording Time,Book and Page
Tax Lot No. 9'3o1-oU�E (Ib0 i40 1
.. ,.... Parcel Identifier No,
Verified by . .... . .County on the day of
by . .. .,.
Mall after recording to Griffin, Caldwell, HELDER,.Lee 6 Helms, P.A.
314 North Hayne Street, Monroe, NC 28110
This instrument was prepared by Jake C. Helder
Brief description for the index
4.0 Ac. Monroe Township
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made this 26th day ttf April_ . is 96
by and between
GRANTOR GRANTEE
GRADY C. SHUMATE (Single) Ty-Par Realty, Inc.,
1111
2042 Lawhon Bluff Road a North Carolina Corporation
Charlotte, NC 28226 P.O. Box 748
f Monroe, NC 28111-0748
(17449
Enter In appropriate block fur each party:name,address,and,if appropriate,cllaraiten of entity,e.g.corporation or porinreshlp.
The designation Grantor and Grantee as used herein shall include Said parties,their helts,successors,and assigns,turd
shall Include singular, plu•nl, masculine, feminine or neuter es required by context.
WITNESSETII, that the Grunlrr, for n valuable consideruliun to-wit: Exchange of Lands
acknowledged,has and by these presents does grant,bargain, selllltatndbconic)' unto litelGra Granthe ee in fee st of impleich Aa all
certain lot or parcel of laud situated in the i'ity of Monroe
Union . Monroe Township,
County,North Carolina and more part icnlu'ly described us follows:
BEGINNING at an iron stake located at the intersection of the
southeastern edge of the right of way of Roland Drive (said right
of way being 40 feet in width) with the southwestern edge of the
right of way of U.S. Highway 74 and runs thence with the southwestern
edge of the right of way of U.S. Highway 74, South 47 degrees 25 minutes
25 seconds East 309.65 feet to an iron stake, a corner of the Ty-Par Realty, Inc. (now or formerly) property (Deed Book 336, page 670); thence
South 42 degrees 46 minutes 49 seconds West 526.56 feet to an iron
. stake; thence North 33 degrees 54 minutes 18 seconds West 421.41 feet
to an iron stake located on the southeastern edge of the right of way
of Roland Drive; thence with the southeastern edge of the right of way
of Roland Drive, North 55 degrees 58 minutes 23 seconds East 440.03
feet to the point and place of BEGINNING, and containing 4.00 acres,
more or less, as shown on survey thereof by Carroll L. Rushing, NCRLS
dated November 2, 1988.
N.C.Mar Mk..►.o.Ne.31)lila,WI riled 1111,
P.o.e.,a..—.K M W NC I.alma..11.1
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The property hereinabova described was acquired by Grantor by Instrument recorded in
•
Deed Book 449, Page 657
A map showing the above described property Is recorded In Plat Book pap
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenance 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 1s marketable and free and clear of all encumbrances,and that Grantor will warrant and
defend the title against the lawful claims of all persona whomsoever except for the exceptions hereinafter stated.
Title to the property hereinabove described Is subject to the following exceptions:
I ,
• 1. Easements and rights of way.
2. Deed of Trust by Grady C. Shumate to Thomas J. Caldwell, Trustee and
Ray M. Williams and wife, Patricia W. Williams, or the Survivor, dated
February 6, 1989 and filed for record in Deed Book A462, page 701 on
1 February 6, 1989 at 4:00 P.M., records of Union County, North Carolina.
3. Modification of Note of even date filed herewith.
nepINa seWn BIY W CR /o tht uGd aonffse rh a.nd sn o l bhie ehseuden.dg ued,:Y afWrty f wawa ao O hUiol nIneleernnw,,ot/a yC !Y d ttne
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le.relaty(Corporal*Seal) Yll
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.w''ka TAMPO NORTH CAROLINA, Union Canty.
/,,4. .•Fin'-. . I.a Notary nubile of t.Canty and state.I.r.ult.ee.elte tat fa1.tttiY...CJ.
i , OTAf�y%.Ill ___S MMeiS'ee. Grantor,
..•.� : i notionally appeared baton me tale day and acknowledged te oneentlea el the fengeag I.otanant.Wilma my
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•.... . .'V•� 1 nana and official gasp or,eaL this 26th�� April is 96
♦., CO.:14\'.., MY commission eaplr,!T :_1. _ Palle
SIAL.ITAtdP NORTH CAROLINA, County.
I,•Notary Public of the County and ,certify that
I personally cam.betel.me thle any and acknowledged that._..he I. eeer.Ury.1
a North Carolina e.Ipor.lion,and that by autheille duly
1 Elva and is the act of the corporation,the refacing inelrument was signed In Ill seam.by It.
r President,sealed with its corporal.seal and ideated by as Ile percolate.
Whom my hand ad official.lair or seal,this day of II
MY commission expire.: Nelda P.btle
Tke lag artNNalele)el Mand.4141.k_.11 •Na004.►3 P Ab L4•40:0‘Co04.1,744 019.
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Ivor.ee,elned Ie Co 5.11.1E the Inslrumml and this militate sere duly reglsler.d at the date and lime aid In th.Deak and rage shown on the
Ilnt pale Mnof. ^e�1(e�
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