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Home My WebLink AboutNCC243201_FRO Submitted_20241021 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 DEC Patterson Ave. RET 2. Location of land-disturbing activity: County Forsyth City or Township Winston-Salem N. Patterson Ave. 36111206 80.242261 Highway/Street Latltude(decimal degrees) LongltUde(decimal degrees) 3. Approximate date land-disturbing activity will commence:08/2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .96 6. Amount of fee enclosed 700 . 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 feeds 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❑ Enclosed ❑x No ❑ 8_ Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Eric Shook E-mail Address eric.shook@duke-energy.com Phone: Office# 704-575-3424 Mobile# 9. Landowner(s)of Record(attach accompanied page to list additional owners): Duke Energy Carolinas, LLC Name Phone: Office# Mobile# 525 S Tryon St. 525 S Tryon St. Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip i 0. Deed Book No.003392 Page No.03654 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). Duke Energy Carolinas, LLC darrin.cardwell@duke-energy.com Company Name E-mail Address 525 S Tryon St. 525 S Tryon St. Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip Phone: Office# 704-382-4021 Mobile# 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: Darrin Cardwell darrin.cardwell@duke-energy.com Name of Registered Agent E-mail Address 525 S Tryon St. 525 S Tryon St. Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip Phone: Office#704-382-4021 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: N/A 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. N/A 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. Darrin Cardwell Manager - Substation Engineering Type or print name Title or Authority Signature Date I, FAM40014 LEw►S , a Notary Public of the County of M►ECKLENBURG State of North Carolina, hereby certify that DRRRti CaR0WELL 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 41"" day of suae , 20 24 49+404, Aaa BRAtdoot4 LEW►S Notary Seal My commission expires JuNE 11,2024 BRANDON MRS 'Wary Public•North Carotin. Motklwiburg County I Ny Commission Expiry Jun 11,2024 Book 3392 Page 3654 2018007411 00063 FORSYTH CO. NC FEE$26.00 STATE OF NC REAL ESTATE EXTX $910.00 PRESENTED&RECORDED 03/01/2018 10:53:57 AM LYNNE JOHNSON REGISTER OF DEEDS BY:OLIVIA DOYLE ASST BK: RE 3392 PG: 3654-3657 Site No.: 114637 Land Unit No.: 1686828 Project No.: 114637-454634 Excise Tax $ 1 16.0 u Recording Time,Book and Page Tax Lot No.: Parcel Identifier No. Verified by County on the day of by Mail after recording to: Duke Energy Carolinas, LLC, Land & Facilities Support Services DEC22A, 550 South Tryon Street, Charlotte,NC 28202 This instrument was prepared by: Karol P.Mack, Deputy General Counsel,Duke Energy Brief description for the Index: 1.296±acres, Forsyth County NORTH CAROLINA GENERAL WARRANTY DEED THIS DEED made as of this 2 F day of ,20 A',by and between GRANTOR GRANTEE UNION BAPTIST CHURCH,INC. DUKE ENERGY CAROLINAS,LLC a North Carolina nonprofit corporation a North Carolina limited liability company 1200 North Trade Street 550 South Tryon Street(DEC22A) Winston-Salem,North Carolina 27101 Charlotte,North Carolina 28202 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. REV 9.8.2015 sca 1 submitted electronically by "Womble Bond Dickinson (us) LLP" in compliance with North Carolina statutes governing recordable documents and the terms of the submitter agreement with the Forsyth county Register of Deeds. Book 3392 Page 3655 WITNESSETH,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 Forsyth County,North Carolina,and more particularly described as follows("Property"): All those certain tracts,pieces,parcels or lots of land located in Forsyth County,North Carolina containing a total of 1.296± acres (comprised of 0.982 acres labeled as Pin#6836-331-0741.00 and 0.314 acres labeled as Pin#6836- 31-0506.00)being more particularly shown on the plat of survey entitled"Property to be Acquired from: Denise W. Warner & Union Baptist Church," dated March 7, 2017, identified as Map: 114637-457591 and Map: 114637- 457592,said Plat attached hereto as Exhibit A and incorporated herein by reference . All or a portion of the Property herein conveyed ❑ includes or ® does not include the primary residence of Grantor. TO HAVE AND TO HOLD the Property and all privileges and appurtenances thereto belonging to the Grantee in fee simple. And Grantor covenants with Grantee, that Grantor is seized of the Property 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: 1. Public streets and roads,visual easements,restrictions and rights of way as may be apparent from a visual inspection of the Property. 2. All matters of survey and recorded plats (including matters that would be revealed by a current, accurate physical survey or inspection of the Property). 3. All such easements,conditions,reservations,restrictions,rights of way and all other matters of record. IN WITNESS WHEREOF,Grantor has caused this instrument to be signed in its name the day and year first above written. [Signatures on Following Pages REV 9.8.2015 sca 2 Book 3392 Page 3656 GRANTOR: Union Baptist Church,Inc. a North Carolina nonprofit corporation By. Print Name: ,5 ` �G� �y Title: /ti i z evi4.*a,4 c 0 4 By: Gz.it Print Nanc, ` ✓/ ��e Title: ,! (-7;/;try' (�✓ i �z r1S' / 0 STATE OF NORTH CAROLINA COUNTY OF FORSYTH I certify that SAMMIE GRAY and CART.ES BOYD personally appeared before me this day,each acknowledging to me that he or she signed the foregoing document. Date: FEBRUARY 28, 121 keiAk D.V AVO1 Notary Public My Commission Expires: 12-06-2020 (No OFFICIAL SEAL DIANE W GERREY NOTARY PUBLIC-NORTH CAROLINA FORSYTI I COUNTY COMM SSION EXPIRES REV 9.8.2015 sca 3 Book 3392 Page 3657 1 ?, • • Y• " .4 i Ew ..egg i d 40 _, , „, . ____ -• ____ _11— * - 3p - -- I_ __ ___ __ _ _,_ _ _ . _ , I li 'I . s ,y ' - s I '. 1 f 'in $ n I'. q' •-_ r %i .'" _4_ �.r ri§ a, cry, , k eta`1 j" '~ � ' i rr Ei 2 It cr 1 —� d.v S 7 r cm —1 y, R 3i a Ile'y - Y g dal F 1 ♦a `sell . ,r. , �, i �Ot \s M..I.SIN7—mr—i.--t Yip 1 IS '{:} --II non I ra i $.R I o ' eb A a 1f-\ "°' Y , ; lto i I i vg . 2 ..-.to !—ws a:x-..ao`\�o sf .51'; $ a l E! • a ; / 9" 'i 4, x1 x m O➢-i i5 r▪ �' -lot- / �i� I 's I 14 �'i O Z v Z b E I / _: q:r.�W6: o n z 5 0 m zO 3 i 4 =`1 5i �:s I cO= mZ d .., a 5 a".1 mmDm0Xm ^$ % `Jp t zzpzar"m $ f 1 i, g I ova ii �mWoximSI, b ig89s F 0 mmO0 ifi F 1 m m-o co m a; � � zmm<o @@ a 1V i cD V 8 n e0■ q D Q r 13 q �tly:11pg � 6A a.;,,1a1• �^+ 5 ; �jf q, '1 fh E n S xl I b !r b ei'e isYiimy, r...., y e 6r \•1 Z i f -fir -� i• �S m m D m r g c 7 6 . i 4 f'i'i't��.$'°i tic g i A R F $• g p I s a%ca3 p� .,goy.... ? 5 !t` e 1 t ;tl 1l i 1; u g pe. i t o .! IC al gl iiii i y•idaV a i!ki :•Or•o�i.®8 ' . , # a`, iS E1 HIS MAP IS NUT A CERTIFIED SURVEY AND HAS NOT BEEN REVIEWED BY A LOCAL GOVERNMENT AGENCY FOR _. COMPLIANCE WITH ANY APPLICABLE LAND DEVELOPMENT REGULATIONS.