NCC242664_FRO Submitted_20240830

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity covered by the Act before this form has been
completed and filed with the City of High Point Engineering Department.
Please type or print and, if question is not applicable, place N/A in the blank.
PART A.
1. Project Name KOTIS PROPERTIES MAIN ST DEVELOPMENT
2. Location of land-disturbing activity: City Guilford
Highway/Street 2511 /2515 N. Main St
3. Approximate date land-disturbing activity will commence: June 2024
4. Purpose of development(residential, commercial, industrial, etc.)
Commercial
5. Approximate acreage of land to be disturbed or uncovered: 57,131.25 SF (1.31 AC)
6. Has an erosion and sedimentation control plan been filed? Yes X No
7. Landowner(s) of Record(use blank page to list additional owners):
Kotis Properties Inc
Name Name
P.O. Box 9296
Current Mailing Address Current Mailing Address
Greensboro NC 27429
City, State,Zip City, State, Zip
336-574-2000
Telephone Number Telephone Number
8. Indicate book and page where deed or instrument is filed(use blank page to list additional deeds or
instruments):
Book 8464 page 559-562
Book Page
FinResFm. Page# 1

PART B.
1. Person(s) or firm(s)who are financially responsible for this land-disturbing activity:
Kotis Properties Inc
Name Name
P.O. Box 9296
Current Mailing Address Current Mailing Address
Greensboro NC 27429
City, State,Zip City, State, Zip
336-574-2000
Telephone Number Telephone Number
2. Registered agent, if any, for the person or firm who is financially responsible:
Signature Mailing Address
Printed Name Telephone Number
3. 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, or if not an individual,by an officer, director,partner or attorney-in-fact, or registered
agent with 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.
David Swift CF0
Type nt e Title of Auth rity
G/ZQZy
gnature Date
a Notary Public of the County ot(JW , State of North
Carolina, do hereby certify that David Swift , appeared personally before me
this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hajl`l,au,� 1,llotarial seal,this day of U , 20/0 .
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My commission expires:
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Book 8464 Page 559
BK: R 8464 1111111 111111M11111111111
PG: 559-562 2021043918
RECORDED. N�FEE$26.00
06-11-2021 GUILFORD COUNTY,NC STATE OF NC
04:22:37 PM JEFF L.THIGPEN REAL ESTATE
BY:MARY BROWN REGISTER OF DEEDS EXTX 5960.00
DEPUTY-GB
Tax Parcel#194639 and 194640
W I new Picker Excise Tax:$960.00
Prepared by:
R.Andrew Harris
f L Wyatt Early Harris Wheeler LLP
1912 Eastchester Drive,Suite 400
High Point,NC 27265
This instrument prepared by R.Andrew Harris,a licensed North Carolina attorney. Delinquent taxes,if any,to be paid by
the closing attorney to the tax collector upon disbursement of closing proceeds.
NORTH CAROLINA SPECIAL WARRANTY DEED
This DEED made this the 1 day of June, 2021 by and between TRIPLE LAND
COMPANY, a North Carolina corporation,whose address is 210 Turner Place, High Point,North
Carolina 27262, (hereinafter referred to as"Grantor") and KOTIS PROPERTIES,INC., a North
Carolina corporation,whose address is P.O.Box 9296,Greensboro,NC 27429,(hereinafter referred
to as"Grantee"). 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:
Pursuant to NCGS 105-317.2,Grantor certifies the property _does X does not include the Grantor's primary residence.
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 of that certain lot or parcel of land lying and being in the City of High Point,County
of Guilford, State of North Carolina and more particularly described as follows:
SEE EXHIBIT 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.

Book 8464 Page 560
2
And the Grantor covenants with the Grantee,that Grantor has done nothing to impair such
title as Grantor received,and Grantor will warrant and defend the title against the lawful claims of
all persons claiming by, under or through Grantor, except for those exceptions described on
Exhibit B attached hereto and incorporated herein by reference.
IN WITNESS WHEREOF,the Grantor has duly executed the foregoing as of the day and
year first above written.
TRIPLE LAND CO 'ANY
By: (SEAL)
Nam P- R. Si doff
Title: ice President
STATE OF North Carolina
COUNTY OF Davidson
I, R. Andrew Harris , a Notary Public of the aforesaid County and
State, do hereby certify that PAUL R. SICELOFF, Vice President, did personally come before me
this day and acknowledge that he executed the foregoing instrument in the name of and on behalf of
TRIPLE LAND COMPANY,a North Carolina corporation,in his capacity as President and having
all requisite authority.
WITNESS my hand and official stamp or seal, this the _ 9th day of
June ,2021.
n rr
NOTARY PUBLIC
My Commission Expires: 11/18/2023
(NOTARY SEAL) W
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Book 8464 Page 561
3
EXHIBIT A
Tract 1:
ADDRESS: 2515 North Main Street,High Point,NC 27262
BEING all of Lot 1 as depicted on the map or plat entitled"Final Property of Siceloff Oil Co."
prepared by Robert P. Guarino,Engineer, dated 6/12/1967 and recorded in Plat Book 41, Page
50, Guilford County Registry;
Tract 2:
ADDRESS: 105 West Peach Tree Drive, High Point,NC 27262
Parcel 1: Being all of Lot 4 as depicted on the map or plat entitled"Final Property
of Siceloff Oil Co."prepared by Robert P. Guarino,Engineer, dated
6/12/1967 and recorded in Plat Book 41, Page 50, Guilford County
Registry, save and except that portion of Lot 4 conveyed to Commercial
Investments of Greensboro,Inc.by deed dated December 23, 1986, and
recorded in Book 3553,Page 241, Guilford County Registry.
Parcel 2: BEGINNING at a nail in the right of way line of West Peachtree Drive,
the common corner of Lots 4 and 5 of the Siceloff Oil Company property
as per plat thereof recorded in Plat Book 41,Page 50 in the Office of the
Register of Deeds of Guilford County,North Carolina; from said
beginning point, South 55° 50' 31"West 26.28 feet along the right of way
line of West Peachtree Drive to an iron pipe; thence, South 36° 32' 20"
East 166.03 feet along the line of the property conveyed to James Allen
Overby and wife by Deed of even date herewith to a new iron pipe in the
line of Lot 7 of the aforesaid subdivision; thence,North 67° 29' 50" East
20.41 feet along the common line of Lots 6 and 7 of the aforesaid
subdivision to an existing iron pipe in the line of Lot 4 of the aforesaid
subdivision; thence,North 34° 21' 40"West 170.01 feet along the
common line of Lots 4,5, and 6 of the aforesaid subdivision to the point
and place of beginning. The same being a portion of Lots 5 and 6 of the
Siceloff Oil Company property as per plat thereof recorded in Plat Book
41,page 50 in the Office of the Register of Deeds of Guilford County,
North Carolina; this tract,when combined with Lot 4 of the aforesaid
subdivision,constitutes new Lot A, containing 0.646 acres,more or less,
of the Exception Map of the property by John Douglas Siceloff and Triple
Land Company,as prepared by Davis-Martin-Powell&Associates, Inc.
dated 1/9/86, Job No. S-22965 (large map).

Book 8464 Page 562
4
EXHIBIT B
[Exceptions]
1. 2021 Ad Valorem taxes;
2. Restrictions,rights of way and easements of record
3. Matters depicted on that ALTA/NSPS Land Title Survey for Kotis Properties, Inc.
prepared by Davis Martin Powell Engineers and Surveyors,dated June 2,2021,Project
#210112