NCC231814_FRO Submitted_20230614

City of Greensboro, NC
Grading Permit Application
GREENSBORO
Owner Information: Permit#:
Company Ruckus Climbing,LLC Contact John Kilburn
Address 3934 Burning Tree Lane Phone No, 910-899-2013
Winston-Salem,NC 27106 Email [e-mail]
Project Information:
Project Name Ruckus Climbing Gym
Address 5005 High Point Rd Latitude 36.0242° Longitude -79.8766°
Greensboro,NC 27407 Tax Map
Area Graded 1.45 Acres and/or sq.ft. Site Area 1.53 Acres and/or sq.ft.
Proposed Use of Property Indoor fitness Zoning C-L(Proposed)
Brief Description of Project Location 767'south of the intersection of W.Gate City Blvd and High Point Rd,site will be on the left.
Brief Description of Development Plan Project consists of a 12,800 sf gym with associated parking,stormwater and utilities.
If this application is approved by the properly designated authorities and a grading permit issued,the undersigned does hereby agree to
comply with all applicable City regulations under the Greensboro Soil Erosion and Sedimentation Control Ordinance as described in
Chapter 30-12-6 of the Greensboro Land Development Ordinance.
Before beginning any grading operation, call f on-site pre-construction meeting, and when area has been protected,call for final
inspection.
Signature of owner,developer,or agent: Date: 3- 50 - 2.zI
FOR OFFICE USE
Approved by Date
Permit No. Date
Tracking No. Date Approved Tracking Type: TRC Grading
Surety Amount Surety Type: LOC SCB HOD Check
Surety Number Surety Expiration Date
Temporary Measures Approved Date
i Final Inspection Approved - - Date

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: Ruckus Climbing Gym
2. Location of land-disturbing activity: 5005 High Point Rd
3. Approximate date land disturbing activity will be commenced: May 2023
4. Development type: Commercial ✓ Industrial_Institutional_MF residential SF residential
5. Approximate acreage of land to be disturbed: 1.45
6. Has an erosion and sediment control plan been filed? Yes No t'
7. Landowner(s)of Record (attach pages to list additional owners):
Valley Brook,LLC
Name Telephone Email
146 Stokley Dr 146 Stokley Dr
Current Mailing Address Current Physical Street Address
Wilmington NC 28403 Wilmington NC 28403
City State Zip City State Zip
8. Deed County: Guilford Book: 4526 Page: 1700
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Dustin Bentley Telephone: [phone]
E-mail: [e-mail] Other:
Part B:
1. Company(ies)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive
list of all responsible parties on an attached sheet.)if the company or firm is a sole proprietorship the name of the owner
or manager may be listed as the financially responsible party.
Ruckus Climbing,LLC-John Kilburn 910-899-2013 [e-mail]
Name Telephone Email
3934 Burning Tree Lane 3934 Burning Tree Lane
Current Mailing Address Current Physical Street Address
Winston-Salem NC 27106 Winston-Salem NC 27106
City State Zip City State Zip

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
Name Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed
name,attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation,
give name and street address of the Registered Agent:
Name Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath (This form must be signed by the Financially Responsible Person if an individual or his attorney-
in-fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there
be any change in the information provided herein.
John Kilburn Owner
Type or print name Title or Authority
3 3 - 25
Sinature Date
I, J i ����� ►" 1�� ��L��I�, a Notary Public of the County of f�5 '11`S (
State of 002 l tC t.c,- , hereby certify that )n ou
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, thisf,t day o /2t h , 20 !/h
► .
My Commission expires Vv--id)Dee_ 17
AULTRICE RICHMOND
Notary Public-North Carolina
Forsyth County
My Commission Expires I L 17 a

CITY OF GREENSBORO
WATER RESOURCES DEPARTMENT
GREENSBORO SEDIMENT AND EROSION CONTROL SECTION
RESPONSIBILITY: The owner of any property within the City limits of the City of
Greensboro where a land-disturbing activity is taking place, shall be solely responsible for any
off-site damage to adjacent property or to City streets (mud and erosion in street), that may
have been caused by the lack of erosion control measures and poor maintenance. The soil
erosion measures detailed on your plans are the minimum required by the City of Greensboro.
When conditions become apparent the owner/developer may be required by the City of
Greensboro to have his/her engineers to design or redesign additional measures/devices to
assure land protection.
1. Erosion Control measures shall be installed prior to grading and according to plans or as
directed by the City of Greensboro's Erosion Control Inspector.
2. The approval of the Erosion Control plan does not mean that additional measures may
not be required to stop off-site sediment.
3. The Owner/Developer shall require the Contractor to take every reasonable precaution
throughout construction to prevent erosion of soil and sedimentation of streams, lakes,
reservoirs, other impoundments, ground surfaces or other property, as required by
Chapter 30, Soil Erosion and Sedimentation Control, of the Code of Ordinances, City of
Greensboro, North Carolina.
4. The Owner/Developer is responsible for maintaining the erosion and sediment control
devices for the duration of the construction.
a. Inspect the site after each rain and periodically to ensure workmanship is according
to plan and site is in compliance with the Erosion Control Ordinance.
b. Repair or replace damaged or inoperative devices as directed by the Soil Erosion
Inspector within a reasonable time or time set forth by the inspector.
c. Keep mud off city streets
5. If eroded soil from the site is deposited on adjacent property, public street or into a
waterway, the Owner/Developer shall be responsible for returning the adjacent property,
city street or waterway to its original condition satisfactorily to the City or the owner of
the property.
6. After placement of asphalt binder on newly constructed street the shoulder shall be
seeded within fourteen (14) days according to the Seeding Specifications.

7. Temporary or permanent groundcover shall be provided on all perimeter areas and
slopes 3:1 or greater within 7 calendar days following completion of any phase of
grading. Provide groundcover for all disturbed areas within 14 calendar days following
completion of construction or development.
8. The Owner/Developer must plan site work so stone placement on drive entrance,
driveway and parking lot can start immediately after fine grading.
9. The Owner or Responsible Party is responsible for the long-term maintenance of the
groundcover on the property. Groundcover must be maintained to a degree that
prevents soil erosion and sedimentation at all times. The City of Greensboro has the
authority to require changes in the owner's groundcover maintenance plan in order to
stop soil erosion and sedimentation at any time.
Section 30-5-5.4 (B)—Specific Civil Penalties
Any person who violates any of the provisions of this chapter, or rules or orders adopted or
issued pursuant to this chapter, or who initiates of continues a land-disturbing activity for which
an erosion control plan is required except in accordance with the terms, conditions, and
provisions of an approved plan, shall be subject to a civil penalty of up to five thousand dollars
($5000.00) per day. No penalty shall be assessed until the person alleged to be in violation has
been notified of the violation by registered or certified mail return receipt requested, or other
means. The notice shall describe the violation with reasonable particularity, give the person a
reasonable time period to correct the violation and state that failure to correct the violation will
result in assessment of a civil penalty of up to five thousand ($5000.00) per day or other
enforcement action including criminal penalties. Each day of continuing violation shall constitute
a separate violation. The city council shall determine the amount of the civil penalty to be
assessed under this subsection and shall make written demand for payment upon the person in
violation, and shall set forth in detail a description of the violation for which the penalty has been
imposed. In determining the amount of the penalty the governing body shall consider the
degree and extent of harm caused by the violation and the cost of rectifying the damage. If
payment is not received or equitable settlement reached within thirty(30)days after demand for
payment is made the matter shall be referred to the city attorney for institution of a civil action in
the name of the city in the appropriate division of the general courts of justice for recovery of the
penalty. Any sums recovered shall be used to carry out the purposes and requirements of this
chapter.
Signature: Date: J z
, - 2 0 z 3
Owner(Print): �� ^ K' l 6&Are\ Date: 3 - so 2' Z3
Project Address: 5005 High Point Rd,Greensboro,NC 27407

DocuSign Envelope ID:4B7DFF1F-1B5D-477D-A32F-A855B29A2149
April 6, 2023
Ruckus Climbing, LLC
Attn:John Kilburn
3934 Burning Tree Lane
Winston-Salem, NC 27106
910-899-2013
Mr. Kilburn,
This letter is to accompany any permitting documentation submitted to state or local agencies with
regard to the development at 5005 High Point Rd.
Valley Brook, LLC,the landowner of the property at 5005 High Point Rd(PIN 7842089784),gives
permission for Ruckus Climbing, LLC,the financially responsible party,to obtain permits for said
property, and by copy of this letter, Ruckus Climbing, LLC has expressed permission from Valley Brook,
LLC to disturb the listed parcel for the purposes of permitting and full development.
DncuSigncd by
At.AA lltn (�VWt
IPfaRVAIIou Green on behalf of Valley Brook, LLC,
4/7/2023

C841 I RG
April 6,2023
Ruckus Climbing, LLC
Attn:John Kilburn
3934 Burning Tree Lane
Winston-Salem, NC 27106
910-899-2013
Mr. Kilburn,
This letter is to accompany any permitting documentation submitted to state or local agencies with
regard to the development at 5009 High Point Rd., Greensboro, NC 27407.
North Carolina 811, Inc.,the landowner of the property at 5009 High Point Rd (PIN 7842087461),gives
permission for Ruckus Climbing, LLC,the financially responsible party,to obtain permits for said
property,and by copy of this letter, Ruckus Climbing, LLC has expressed permission from North Carolina
811, Inc.to disturb the listed parcel for the purposes of permitting and full development in alignment
with the permit plan dated 4-6-23.
Louis Panzer
Executive Director
on behalf of North Carolina 811, Inc,