NCC221606_FRO Submitted_20220426

GUILFORD COUNTY
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
DEPARTMENT OF PLANNING AND DEVELOPMENT
A Grading Permit must be obtained before initiating any land -disturbing activity over one (1) acre (43,560 square feet). A
Grading Permit Application, this Financial Form, a Grading/Erosion Control Plan, a surety, good for one (I) year, and a
permit fee should be submitted 30 days prior to the planned commencement of the land -disturbing activity.
The above information should be submitted to:
Please type or print ans►vers to the following:
Date: November 19, 2021
Name of Project: Saba, Auto Sales & Service Center
Location of Project: 7962 National Service Rd
Earl E. Davis 11 - Inspections Division
Guilford County Planning and Development
Post Office Box 3427
Greensboro, N.C. 27402 [phone]
Acreage of Land to be Disturbed: 2.69Acres
LATITUDE 36.085511 (In Degrees) LONGITUDE -79.980614 (In Degrees)
Purpose of Activity (street construction, commercial building, parking lot, etc.): Commerical auto sales and service center with parking
Landowner(s) of record:
Name: National Services NC, LLC
Address: 8706 Berne Rd
Colfax, NC 27235
Name:
Address:
Telephone: (Home) Telephone: (Home)
(Office) (Office)
(Fax) A (Fax)
(E-Mail) t (E-Mail)
Indicate County, Book, and Page where deed or instrument is filed.
Guilford
County
8410
Book
1856
Page
The information provided on this form is true and correct to the best of my knowledge and belief and was provided by
me while under oath. This form must be signed by the property owner if an individual. If owned by a company or
corporation, this form must be signed by an officer, director, partner, attorney -in -fact, or other person with authority to
execute instruments for the corporation. If the person financially responsible is not a resident of North Carolina, a North
Carolina agent must be designed. If someone other than the owner is financially responsible, their signature is required
below also.
Jaryan Hammood
Print or Type Name of Individual
Manager - National Services NC, LLC
N. C. Agent's Signature (if applicable)
Title an om Additional Financially Responsible Party (if applicable)
er's 5ignature
No. E2 Grading Permit & Appl. Rev. December 2017 Page 3 of 6