NCC222429_FRO Submitted_20220715

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 daysprior to the planned commencement of the land -disturbing activity.
The above information should be submitted to:
Please type or print answers to the fallowing:
Date:
NameofProject: P9ECA5T 5DiuiiL.45_FHA5
Earl B. Davis II - Inspections Division
Guilford County Planning and Development
Post Office Box 3427
Greensboro, N.C. 27402 [phone]
Location of Project: C14ar-74a A14D Si1fIS�[fi�N� tr'ra
Acreage of Land to be Disturbed: i-Z,qO AC5
LATITUDE 3&494847 ° (In Degrees) LONGITUDE 7q,'713,j51,' (in Degrees)
Purpose of Activity (street construction, commercial building, parking lot, etc.): C1 riSii j14T CoIJLR ETiF BATC;4 PLAN -41 f 9014(, rt1EA
Landowner(s) of record:
0440 i4AgRE1aL
Name: 9LUE IZ106aw LAn a YtaLf3lPia G
Address: -LftZ BETREL V}SuLT
QAk 9WI�E , NC 271ja
Telephone: (Home)
(Office) tRL) 654- 7419
(Fax)
(E-Mail) ;onS'cem
—r
Name:
Address:
Telephone: (Home)
(Office)
(Fax)
(E-Mail)
Indicate County, Book, and Page where deed or instrument is filed.
PS 6033 PG 20g7-
G'li L o F P M 9527 rG Zozr
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.
C1a417 HA91ZI i. L
Print ouK11
ype Name of Indivi 1
Je"� T«car I4_4
Title annAN4me ofCompapyk
Owner's Signature
N. C. Agent's Signature (if applicable)
Additional Financially Responsible Party (!f applicable)
No. 1 2 Grading Permit & App1. Rev. December 2017 Page 3 of

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 A/09 j CAROLWA
COUNTY OF Gult-FO 2A
(OWN 'S SIG NA RE)
1, a Notary Public of said County and State, do hereby certify that
Ci A2 4A/Z9EU- 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 23 & day of l" e—Cq , 2012.
s��H�,�eutgir
Nntaru����. �. 1���+►s.
My Commission Expires: y4 OTA
MA9444 zb, Z615 �
(SEr� .oCj
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 we 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
My Commission Expires:
day of 20
Notary Public
(SEAL)
No. E2 Grading Permit & Appl. Rev. December2017 Page 4of6