NCC231530_FRO Submitted_20230531

BT SOUTH WAREHOUSE, 4416 Groometown Road, Greensboro, NC 27407, Case# 22-03-GCCP-01562
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 II-Inspections Division
Guilford County Planning and Development
Post Office Box 3427
Greensboro,N.C.27402(336)641-3334
Please type or print answers to the following:
Date: August 11,2022
Name of Project: BT South Warehouse Addition
Location of Project: 4416 Groometown Rd., Greensboro,NC 27407
Acreage of Land to be Disturbed: 3.0 acres
LATITUDE 35.995250 (In Degrees)LONGITUDE -79.865950 (In Degrees)
Purpose of Activity(street construction,commercial building,parking lot,etc.): Warehouse/Storage Building
Landowner(s)of record:
Name: 4416 Groometown Road, LLC Name:
Address: 4416 Groometown Road Address:
Greensboro, NC 27407
Telephone: (Home)
(Office) [phone] Telephone: (Home)
(Fax) (Office)
(Fax)
(E-Mail) (E-Mail)
Indicate County,Book,and Page where deed or instrument is filed.
Guilford 4134 325
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 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.
A LA&/ (_132/Z0LL
Print or Type Name of Individual N. C.Agent's Signature (if applicable)
Groome wn Road, L C
Tithe parry Additional Financially Responsible Party(if applicable)
Owner's Sign e
No.E2 Grading Permit&Appl. Rev.December 2017 Page 3 of 6

BT SOUTH WAREHOUSE, 4416 Groometown Road, Greensboro, NC 27407, Case# 22-03-GCCP-01562
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
BT South Warehouse Addition [phone] or(336)641-3880(fax)
NAME OF PROJECTST South Warehouse Addi.DATE: 8/11/2022
LOCATION OF PROJECT: 4416 Groometown Rd.,Greensboro, NC 27407
ACREAGE TO BE DISTURBED: 3.00 ACRES OR(130,680 SQ.FEET)
TOTAL ACREAGE IN TRACT: 7.543 ACRES
IS THIS PROPERTY IN A DESIGNATED WATERSHED? Yes. Lower Randleman Lake WS-IV
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.) Relocation of Well Water Supply
ENGINEER/ARCHITECT/SURVEYOR: Name: Covington&Associates
Address: 811 Eula Street, Suite B, Greensboro, NC 27403
Telephone: [phone] y
Fax: N/A
E-Mail: [e-mail]
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: 4416 Groometown Road,LLC Name:
Address: 4416 Groometown Rd.Greensboro, NC 27407 Address:
Telephone: (Home)
(Office) [phone] Telephone: (Home)
(Fax)
(E-Mail) (Office)
(Fax)
(E-Mail)
Print Name:
Signature:
ADDITIONAL FINANCIALLY RESPONSIBLE PARTY:
Name: Telephone: (Home)
Address: (Office)
(Fax)
(E-Mail)
Print Name:
Signature:
No.E2 Grading Permit&Appl. Rev.December 2017 Page 2 of 6

BT SOUTH WAREHOUSE, 4416 Groometown Road, Greensboro, NC 27407, Case# 22-03-GCCP-01562
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 \\ \ C (OWNER'S SIGNATURE)
COUNTY OF uS FUri
I,a Notary Public of said County and State,do hereby certify that
�Ne n C'(v 1 D i t 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 't5-th day of PIA0 2012.
davu\ck L,\N\rOon
TAM ALA LIVINOWINPublil
My Commission Expires: NOTARY PUBLIC
j�{�!„) LLt r� i' �, Guilford County, North Carotin
' ` E1 My Commission Expires May 24. 2
(SEAL)
*************************************
STATE OF (ADDITIONAL FINANCIALLY RESPONSIBLE PARTY SIGNATURE)
COUNTY OF
I,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
Notary Public
My Commission Expires:
(SEAL)
No.E2 Grading Permit&Appl. Rev. December 2017 Page 4 of 6