NCC222847_FRO Submitted_20220818

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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:
Earl E. Davis H - Inspections Division
Guilford County Planning and Development
Post Office Box 3427
Greensboro, N.C. 27402 [phone]
Please type or print answers to the following:
Date: 5128� Z4-z
Name of Project: Fe((Au_&e thht i�� i � web �(1� t.(CG
Location of Project: -1115 6FJ ks-kisudle- �uti
Acreage of Land to be Disturbed: 2 r S W
LATITUDE 3 �, 22 t ! i (In Degrees) LONGITUDE " 7Q 7a �% 2 33 (In Degrees)
Purpose of Activity (street construction, commercial building, parking lot, etc.): _ C:i»rne<<%�i;�dlr�•, .4- of
�•
Landowner(s) of record:
r( _� ! L
Name: , TrtC �'�urcl� C���JI Name:
Address: V 0 l N�- W y 15 o E4� Address:
.3r .{n' G r !LfL-
Telephone: (Home) Telephone: (Horne)
(Office) (Office)
(Fax) (Fax)
(E-Mail) (E-Mail)
Indicate County, Book, and Page where deed or instrument is filed
6(Ail914 l(2 2
County Book
D! 6$
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.
N. C. Agent's Signature (if applicable)
Additional Financially Responsible Party (If applicable)
No. E2 Grading Permit & Appl.
Rev. Deeember 2017 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).
STATEOF /llZle-7H C4A9D,1ell-2 OWNER' 1 NA
COUNTY OF
h a Notary ublic of said C.y and State, do hereby certify that
appeared before me this day and under oath acknowledged reading the
information ab a and acknowledged that the above form was executed by him or her.
Witness my hand and official seal, this the �_ day of --�A , 20:;,?/
���i a�l -"4z
Notary Public
�i��►
My Commission Expires:
(SEAL) ibOat I G 4
STATE OF (ADDITIONAL FINANCIALLY RESPONSIBLE PARTY SIGNATIM
COUNTY OF
1, a Notary Public of said County and State, do hereby certify that
personally appeared before me this day and under oath acknowledged reading the information above and
acknowledged that the above form was executed by him or her.
Witness my hand and official seal, this the day of 20 —
My Commission Expires:
Notary Public
(SEAL)
No. E2 Grading Permit & Appl. Rev. December 2017 Page 4 of 6