NCC222050_FRO Submitted_20220601

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 answers to the following:
Date: 12/15/2021
Name of Project: Steeplegate
Location of Project: Brick Church Road
Earl E. Davis II - Inspections Division
Guilford County Planning and Development
Post Office Box 3427
Greensboro, N.C. 27402 [phone]
Acreage of Land to be Disturbed: 4.5
LATITUDE 36.006597 (In Degrees) LONGITUDE-79.558184 (In Degrees)
Purpose of Activity (street construction, commercial building, parking lot, etc.): Roadway construction
Landowner(s) of record:
Name: Venn Steeplegate, LLC
Address: 3140 S Church Street
Burlington NC 27215
Telephone: (Home)
(Office)
(Fax)
(E-Mail)
Indicate County, Book, and Page where deed or instrument is filed.
Guilford
8452
Name:
Address:
Telephone: (Home)
(Office)
(Fax)
(E-Mail)
County Book Page
1376-1380
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.
Shawn Cummings
Print or Type Name of Individual
Managing Member Venn Steeplegate, LLC
Title Name of Comp
Owner's Signature
N. C. Agent's Signature (If applicable)
Additional Financially Responsible Party (If applicable)
No. E2 Grading Permit & Appl. Rev. December 2017 Page 3 of 6