NCC221974_FRO Submitted_20220526

GUILFORD COUNTY
GRADING PERMIT APPLICATION
GRADING PERMIT APPLICATION
Please type or print answers: Return to: Earl E. Davis II Inspection
Planning and Development
Post Office Box 3427 Greensboro, NC 27402
[phone] or [phone] (fax)
NAME OF PROJECT: Dollar General DATE: 1/4/2022
LOCATION OF PROJECT: 5904 Church Street
ACREAGE TO BE DISTURBED: 1 .99 acreS ACRES OR( Q. FEET)
TOTAL ACREAGE IN TRACT: 1.23 ACRES
IS THIS PROPERTY IN A DESIGNATED WATERSHED? n/a
If so, the project must comply with Guilford County Regulations prior to a Grading Permit being issued.
WHAT TYPE OF UTILITIES WILL GO IN DURING CONSTRUCTION? (Water, Sewer, Power, Cablevision
Telephone, etc.) Water, Septic, Power, Telehpone
ENGINEER/ ARCHITECT/ SURVEYOR: Name: BREC, PA Justin Church
Address: 1520 Meadowview Drive Wilkesboro NC 28697
Telephone: [phone]
Fax:
E-Mail: Justin@brec biz
The Property Owner and additional Financially Responsible Party (if any) do hereby agree to comply with all applicable
Guilford County Regulations pertaining to development if a Grading Permit is issued. The Property Owner and additional
Financially Responsible Party furthermore, do hereby agree to be responsible for the timely installation and maintenance of
erosion control devices throughout the duration of this project. A copy of the Guilford County Development Ordinance is
available from the Guilford County Planning and Development Department.
OWNER OF PROPERTY: NORTH CAROLINA AGENT (if applicable)
Name: Buster Glossop
Name:
Address: 6935 Baltusrol Lane Charlotte NC 28210 Address:
Telephone: (Home)
(Office) Telephone: (Home)
(Fax) (Office)
(E-Mail) (Fax)
(E-Mail)
Print Name: Bust losson
Signature:
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY:
Name: Teramore Construction, LLC Telephone: (Home)
Address: 214 Klumac Road - Suite 101 (Office) 704-224-7364
Salisbur NC 2 4 (Fax)
(E-Mail) [e-mail]
Print Name: Joe Stric d
Signature:
No. E2 Grading fermit & Appl. Rev. December 2010 Page 2 of 6

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 (1) 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 answers to the following:
Date: 01 /04/2022
Name of Project: Dollar General
Location of Project: 5904 Church Street Greensboro
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: 1 99 aGrpS
LATITUDE 36 219222 (In Degrees) LONGITUDE -79.7877423 (In Degrees)
Purpose of Activity (street construction, commercial building, parking lot, etc.): Commercial Building
Landowner(s) of record:
Name: Buster Glosson
Name:
Address: 6935 Baltusrol Lane Address:
Charlotte NC 28210
Telephone: (Home)
(Office)
(Fax)
(E-Mail)
Telephone: (Home)
(Office)
(Fax)
(E-Mail)
Indicate County, Book, and Page where deed or instrument is filed.
Guilford 6439 1401
County Book 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 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.
4k_-5w-,/J
Print or Type Name of Individual
ZTiand Name of Company
e gn'at ure
N. C. Agent's Signature (If applicable)
Additional Financially Responsible Party (If applicable)
No. E2 Grading Permit & Appl. Rev. December 2010 Page 3 of 6

PLEASE READ THE FOLLOWING INFORMATION:
If a Grading Permit is issued it is valid for up to one (1) year from the date it is issued. If circumstances warrant it, it may
be extended for six (6) months after the one (1) year period. Upon written notice the Grading Permit may be revoked for
failure to install devices as shown on the plan in a prompt fashion, or for failure to maintain the devices once they have
been installed. If a Grading Permit is revoked, all other development permits and approvals are withheld until the property
is once again in compliance with Guilford County regulations. Also, upon written notice a Civil Penalty (fine) can be
instigated against the property owner and/or additional Financially Responsible Party (if any) for violations of Guilford
County's Soil Erosion and Sedimentation Control Ordinance. This penalty is up to $5000.00 per day and is assessed daily
for every day the property is in violation. (Interfering with or hampering an inspection can result in a civil penalty without
written notice).
STATE OF Nd t 7.1/ C -1;Q U L-1,y,4
COUNTY OF l`XEC K L L NIA tl R
(OWNER'S SIGNATURE)
I, a Notary Public of said County and State, do hereby certify that
l3 u; r 2 C. (� L 6 SS e:y personally appeared before me this day and under oath acknowledged reading the
information above and acknowledged that the above form was executed by hip or her.
Witness in _harid-and-offcial- , ' the
DANIEL R AL.MAZAN
NOTARY PUBLIC
Rowan County
North Carolina
M} Commission Expires June 25, 2022
My Commission Expires:
JUNT 25. Z c.2,Z
/ 67-Al day of fZ,6,QVA' /1)/,20'Z2,
Notary Public
(SEAL)
STATE OF AJ 6.1 r L( ("4A CLL IV4 (ADDITIONAL FINANCIALLY RESPONSIBLE PARTY SIGNATURE)
COUNTY OF 12 U �,//1,'\%
Ic a 1Aota�y Public of said County and State, do hereby certify th
personally appeared before me this day and under oath ack owledged reading the information above and
acknowledged that the above form was executed by him or her.
Witness my hand and official seal, this the 16 %`I day of 46AV,14-7207-Z-
My Commission Expires:
DNS 25,-2u-2
- �r,,ikELRALMAZAN
NOTARY PUBLIC
Rowallon I)
+�i�lan Expires June 25, 2022
No. E2 Grading Permit & Appl. Rev. December 2010 Page 4 of 6