NCC232022_FRO Submitted_20230725

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.
314 Painted Trails Lexington NC Lot 22 Wynnfall
1. Project Name
2. Location of land-disturbing activity: County Davidson City or Township Lexington
Highway/Street Painted Trails Latitude(de�Emel degrees)35`9075 Longitude(de�tmaI degrees)-80.2373
3. Approximate date land-disturbing activity will commence: May 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):0.48 AC
6. Amount of fee enclosed: $ 0Q.Do . 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 0 Enclosed II No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John Hersome E-mail Address [e-mail]
3365773388
Phone: Office# Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Siena Signature Homes Inc 3365773388
Name Phone: Office# Mobile#
195 Burkeview Court
Current Mailing Address Current Street Address
Lexington, NC 27295
City State Zip City State Zip
2586 1858
10. Deed Book No. Page No. 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).
Siena Signature Homes Inc [e-mail]
Company Name E-mail Address
195 Burkeview court
Current Mailing Address Current Street Address
Lexington NC 27295
City State Zip City State Zip
3365773388
Phone: Office# 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:
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
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
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.
John Hersome Builder
Type or print na e Title or Authority
- .fit,� _ ` = -2y- t G.
Signature Date
cC! P4iC , a NotarylI Public of the County of -
State of North Carolina, hereby certify that � ✓1n ki.2/ iCb1/4-Q- 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 2li- day of 1 /1,iul , 20 3
•
MONICA E. PUCKETT • Notary
Notary Public-North Carolina Forsyth County My commission expires

2023002278
DAVIDSON COUNTY NC FEE$26.00
STATE OF NC REAL ESTATE EXTX
$102.00
PRESENTED&RECORDED
02/10/2023 01:11:39 PM
MICHAEL E. HORNE
REGISTER OF DEEDS
BY:CASEY L.RAINO
DEPUTY
BK: DE 2586
PG: 1858-1859
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $102.00
Parcel Identifier No.: 11307J0000022(Tax PIN:6738-01-37-7415)
Mail tax bills to Grantee: 195 Burkeview Court,Lexington,NC 27295
This instrument was prepared by; T.Thomas Kangur,Jr.,a licensed North Carolina attorney.Delinquent taxes,if any to be paid
by the closing attorney to the county tax collector upon disbursement of closing proceeds.
Brief description for the Index: Lot 22,Wynnfall
THIS DEED made this 25th day of January ,2023,by and between,
GRANTOR GRANTEE
BUEL B. BARKER,JR. and wife, SIENA SIGNATURE HOMES,INC.
VICKIE B.BARKER a North Carolina corporation
Mailing Address: Mailing Address:
3632 Friedburg Church Road,Winston-Salem,NC 27127 195 Burkeview Court,Lexington,NC 27295
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 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 Davidson County,North Carolina and more particularly described as follows:
Being known and designated as Lot No.22,as shown on the map of WYNNFALL,PHASE ONE,as recorded
in Plat Book 84,Page 57,in the office of the Register of Deeds of Davidson County,North Carolina,reference
to which is hereby made for a more particular description.
Property Address: 314 Painted Trail,Lexington,NC 27295
The property does not include the primary residence of the Grantor.
The property hereinabove described was acquired by Grantor by instruments recorded in Book 2447,Page 1129,Book 2427,Page
1177,and Book 2563,Page 106 Davidson County Registry. A map showing the above-described property is recorded in Plat Book
84,Page 57.
Submitted electronically by "Kangur & Porter, LIP"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Davidson County Register of Deeds.
2023002278

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,
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,other than the following exceptions: Subject to all easements, rights-of-way and
restrictions of record,if any,and ad valorem taxes for the current year.
IN WITNESS WHEREOF,the Grantor has duly executed the foregoing as of the day and year first above written.
(SEAL)
Buel B. Barker,Jr.
4 13 r ,7 36 � ) -(SEAL)
Vickie B.Barker �
State of North Carolina,County of Forsyth
I certify that the following person(s)personally appeared before me this day,each acknowledging to me that he or she voluntarily
signed the foregoing document for the purpose stated herein and in the capacity indicated:Buel B.Barker,Jr and Vickie B.Barker
Date:
qa-i4;e6;4-,
1
Notary Public PATRICIA F. KIRKMAN
11 1 1 . `, / ( Notary Public-North Carolina
t' ! Forsyth County
printed or typed name of notary public — -
My Commission Expires: C./41 /7 T
2023002278