NCC231934_FRO Submitted_20230622

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: 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: 03/06/2023
Name of Project: Commons Summit Lakes
Location of Project:8001 Brooks Lake Road Browns Summit,NC
Acreage of Land to be Disturbed: 5 95
LATITUDE 36.2297 (In Degrees)LONGITUDE 79.7192 (In Degrees)
Purpose of Activity(street construction,commercial building,parking lot,etc.):Street construction for Residential Development
Landowner(s)of record:
Name: Summit Lakes II,LLC Name:
Address: PO Box 415 Address:
Browns Summit,NC 27214
Telephone: (Home) [phone] Telephone: (Home)
(Office) (Office)
(Fax) (Fax)
(E-Mail) [e-mail] (E-Mail)
Indicate County,Book,and Page where deed or instrument is filed.
Guilford 4360 1160
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.
Daniel Mosca
Print or Type Name of Individual N. C.Agent's Signature (if applicable)
Summit Lakes II, LLC _
T' •
d ne ompany Additional Financially Responsible Party (if applicable)
ner's Signature
No.E2 Grading Permit& Appl. Rev. December 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 (I) 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 NWelt% 4.Qi91II10, ` OWNER'S IGNATURE)
COUNTY OF C�►u�\ r d,, 1 fa
I;a Notary Public of said County and State,do hereby certify that
-DA"l et IM 0 SCo. 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 'y day of Mach ,20 n.
SUZANNE M THOMASSON
NOTARY PUBLIC GUILFORD COUNTY,NC i UW�
►y Commission apses 11-o5-26" 1
- Notary Public
My Commission Expires:
1'L-OS- 2o1.-1
(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

GUILFORD COUNTY GRADING PERMIT REQUIREMENTS
A grading permit must be obtained before any area over 43,560 square feet(one(1)acre)is grubbed or graded.
The Inspections Division requires that four(4)copies of the Erosion Control/Grading Plan be submitted for review thirty(30)days
prior to commencement of activity.
An Application and Financial Ownership Responsibility Form must be submitted and signed by the property owner or one who has
power-of-attorney for the owner. (North Carolina resident signature required. if person financially responsible is not a
resident of North Carolina).
A surety is required before a grading permit can be issued. The amount is determined by multiplying $1,500.00 x acre(s) disturbed
($2,000.00 per acre for landfill).The property owner must provide this.A surety must be cash,cashier's check,performance bond,
Irrevocable Letter of Credit,or escrow account payable to Guilford County.
Pay the appropriate grading permit fee (see fee schedule). One(I)copy of the Erosion Control/Grading Plan must be sent to the Soil
and Water Conservation District for their review if the disturbed area is greater than one(1)acres.Mail to:3309 Burlington Road,
Greensboro,N.C.27405,Telephone Number 336-375-5401.
COMPONENTS FOR A COMPLETE EROSION CONTROL/GRADING PLAN
Name of Project Construction Sequence
Name,Address and Telephone Vicinity Map
Number of Owner(s) Soil Type(s)
Engineer,Architect or Surveyor's Seal Adjoining Property Owner(s)
Engineer,Architect or Surveyor's Name, Tax Map Number(s)
Address and Telephone Zone of Property
North Arrow Total Acres in Tract
Scale and Legend of Symbols
Area to be disturbed outlined with number of graded acres noted.(Easements are to.be included if they will be disturbed).
Area left undisturbed and condition of such(vegetated?)should be denoted with size indicated.
All creeks,rivers,ponds,lakes,railroad tracks,existing structures,etc.,should be noted.
Proposed site improvements should be noted (roads,parking,easements,structures,etc.). Submit one(I)copy of street profiles.
Temporary sediment control measures(design, locations,dimensions,calculations,cross-sectional details).
Permanent erosion control measures(design,locations,dimensions,calculations,cross-sectional details).
Stormwater Network(swales,culverts,inlet and outlet structures with grades,elevations,dimensions and hydrologic calculations).
Include design storm.
Seeding specifications(seedbed preparation,lime,fertilize,seed,mulch and tack rates).
Topography,both before and after grading,with elevations noted off edge of property.
Watershed requirements are to be reflected on the Erosion ControVGrading Plan.
No.E2 Grading Permit&Appl. Rev.December 2017 Page 5 of 6

GUILFORD COUNTY Fee Schedule
PLANNING AND DEVELOPMENT Incorporated &Unincorporated
Grading Permit
Soil Erosion Division
GRADING PERMIT FEES
EFFECTIVE JULY 1, 2017
AMOUNT DISTURBED BASE FEE
One (1) acre (43,560 SF) $450.00
but less than Three(3) acres
Three (3) acres or more $450.00 plus
$225.00 per acre for each
additional acre*
EXAMPLES:
GRADED AREA FEE
3.0 acres up to 3.9 acres $675.00
4.0 acres up to 4.9 acres $900.00
5.0 acres up to 5.9 acres $1125.00
6.0 acres up to 6.9 acres $1350.00
7.0 acres up to 7.9 acres $1575.00
8.0 acres up to 8.9 acres $1800.00
9.0 acres up to 9.9 acres $2025.00
10.0 acres up to 10.9 acres $2250.00
11.0 acres up to 11.9 acres $2475.00
12.0 acres up to 12.9 acres $2700.00
13.0 acres up to 13.9 acres $2925.00
14.0 acres up to 14.9 acres $3150.00
15.0 acres up to 15.9 acres $3375.00
16.0 acres up to 16.9 acres $3600.00
17.0 acres up to 17.9 acres $3825.00
18.0 acres up to 18.9 acres $4050.00
19.0 acres up to 19.9 acres $4275.00
20.0 acres up to 20.9 acres $4500.00
21.0 acres up to 21.9 acres $4725.00
22.0 acres up to 22.9 acres $4950.00
23.0 acres up to 23.9 acres $5175.00
*Guilford County has a maximum fee of$8325 @ 38+acres
Schedule Fee Soil Erosion Eff. 7-1-17 Page 1 of l
Revised 07/07/2017
No.E2 Grading Permit&Appl. Page 6 of 6
Rev..December 2017