NCC221300_FRO Submitted_20220405

GUt"ORD COUNTY
FINANCIAL RESPONSIBILITYIOWNERSHM FORM
DEPARTMENT OF PLANNING AND DEVELOPMENT
Grading Permit must be obtained before initiating any land -•disturbing activity over one (I) acre Iquare (43,560 s
Grading Permit i�pplicatiot4 this Financial Form, a Grading/Erosion Control plan, a surety, feet). A
good for one re
permit fee should be submitted 3f3 da s i r to the plamied ccssrtzrtertcement of tite l,%Id_disturbing activity, () year, and a
The above Information should be Submitted to:
.art F-. Davis II w irSpectitans Division
Guilford county planning and Development
Post Office Box 3427
Please type or pint to theft lowing, Greensboro, N.C. 27402 (336) 641..3334
Namo of Project•
L40mtim of Project:
Acreage of Land to be )r?sstarbm: _ 3. o
LATITUDE � �` �S �
— �---$._._ _- - (In Degrees) r.OMGI1 i].UE--may & O � ri e
Purpose of ' ity (stroct Construction, commercial isuilding, parking /Eat, etc.): � -- (In Dofyees)
a
LsudcaV(s) of rcnortF.
Address: 2 fit.1. Aire I~ Naze: ._.,,�_
' IV- a { s, Address:
Tclopbotte: (i ooze) - ,ram x ?-/Vo
(Office) TelepIzone: {140;ne)
(Fax)—�._.---_ —_ (office)
(E-Mait) _.._ _.. (Fax)
Jadicate County, Baok, and rage whem deed or instrument is fled..
614;j ford
The information provided on this farm is true and correct to the best of my knowledge and belief and Was Provided by
trac wla%ie under raAtb. 'I°ht�I_h.�s.-_.fr?? m.-• t be sz�.ed by the o e owner if rsti individual. If avrned by a company or
c*Toration, this form must be signed by an officer, director, parmer, atto ey-in-fact, or other pergon with authori
ty to
execute instruments ftar tite corporation. If the et'son finaanciall re, nsib e is riot a resident Of North Carolina a North
�rolina a ent must be deli zd. If someone Other than the owner is financially responsrble., their signa�e is required
below also.
Prim or Type a of Individ
— ) - }! � - N. G..Age-it`s Signature (if applicable)
Ti Ile and e f oar: ny,
- Additional Financially Kespoalsiblo Party (if applicable)
No. E2 Gmdu g Permit & Appl.
itev. Weember 2017-------- .—
Pago a of 6

�LLL?Wi1VG i1t�FU1sATil]N.
If Grading permit. is iss red it is valid for up to one (1) Year from the date it is issued If circumstances waraant it, it xtaa
be extended for six (f,) moms after the one (l) year Period. Upon written notice the 3
failure to install devices as shown on the plan in a prompt fashion, or for failure to maintain the devicesyonceetlae d o
been installed. If Grading Permit is revoked, all other development permits and approvals are withheld until the o � e
rty
is once again in compliance with Guilford County
instigated against the Pml�eY owregulations. Also, upon written notice a Civil Penalty (fircel can be
ner dfor additional Financially Responsible Party (if any) for violations of Guilford
Connty's Soli Erasion and Sedimentation Caca#xnI Ordinance- This Penalty's up to $5000.00 per day and is assessed dail
for every day the property is in violation. (interfering with car hampering an inspection can result in a civil penalty without
written notice),
STATE CIF Aa746, t, —
C:t7rTiVW Cal" dK WNER'S SIGN )
�tI, a Notary Public Of said County and State, do hereby certify that --
11 aw-S penOnally appeared before we this day and under oath acluaOwledged rmdiri tine
information above and act iuwledged that. tine above form Was executed by Intro car her. g
Witness my hwid and official seal, this the T71—
day of e�".
My COMMission Fixpires: Notary Public
DIXON �lTr
NOTARY PUBLIC
FORSYTH COUNTY, NC
My Commission t Mpires Z lt% Zb
(SEAL)
STATE OF
ADDMONAL ONANCIALLY KESPON LE PA tTY SIGNATURE
COUNTY O
I, a Notary Public of said County and State, do hereby certify that
� personally appeared before me this coy and under oath acknowiedge-d.reading the information above and
acknowledged that: the above form was executed by hurt or her,
Wittress my band and official seal, this the
--"-_ clay of
MY Commission Expires:
Notary Public
(SEAL)
20
No. F2 Grading Permit- & A ,.
Dercinber 20 ] 7
Page 4 of fi

GUILFORD co NTY
GRADING PERMIT APPLICATION
GRADING PERMIT APPLICATION
Please type ar print ans-veers; Return to: Earl R Davis E Inspection
Planning and Development
Post Office Box 3427 Greensboro, NC 27402
[phone] or (336) 641-38SO (jax)
NAME OF PR0JECT: __k_C_C3P DATE: _ ZC Z 2_
LOCATION OF PROJECT- - drpy b qef
ACREAGE TO 13E DISTURBED: 3r O .ACRES OR Z52—sQ FEET)
TOTAL ACREAGE IN TRACT:ACRES
IS THIS PROPERTY IN A DESIGNATED WATERSHED? j: s'q 1wh ts/ S _ �
If'so, the project mast comply with Guilford County Regulations prior to a Grading Permit being issued.
WHAT TYPE OF UTILITIES WILL GO IN DURING CON iTRUCTION`? (`Water, Ser�rer, Paver, ued. isian,
CabTelephone, etc.} �Cs�`
ENGIrNEEW ARCHITECT/ SURVEYOR: Name:
Address: J�Ze.� :o w r tq�ts,S • , � , dil 21 I "�
Telephone: _ 3 3(o "7 �y,-
Fax: #+�
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 fur#hemore, do Hereby agree to be responsible for the ti3nely ins lla#icon and maintenance of
erosion control devices throughout die duration of t�is projeci, A copy of the Guilford C OuntY Development Ordinance is
available front the Guilford County Planning and Development Department.
OWNER OF PRO ERTY;
_
Name: C SIG G
NORTH CAROLI;NA AGENT �%�crpplfcrri�te)
Address: if ZS ,n3 S.7� 5
Telephone: (Dome)�—
Nam,
Address:
--
—.._�_.
(©ice)
(p�) — —
T
Telephone:
(Home)-
(E-Mail) -
(Office)
Pj int
(Fax)
Signature;
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY:
Name:
Address; — —
Telephone.
(€-lowc)
—
(Of%ce)
--- _
(Fax)
-
(E-hail) _
Print Name:
Signature:
No. E2 Grading Pmmit & App1. Rev. December 2017 --��-- �—
Page 2 of 6