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Home My WebLink AboutNCC222661_FRO Submitted_20220726City of Winston-Salem Field operations Department ( Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WIRS10115illell1 Mailing: PO Box 2511, Winston-Salem,, NC 27102 Financial Responsibility/Ownership Form No person may initiate any land -disturbing activity exceeding 20,000 square feet for Single -Family Dwelling construction, 10,000 square feet for any other non-exempt purpose, or part of a larger common plan of development exceeding these thresholds, before this form and an acceptable Erosion. Control Plan have been submitted, reviewed, and approved by the City of Winston-Salem Erosion Control Division and a Grading/Erosion Control Permit has been issued. Please type or print. Please place "N/A" in the blank space if not applicable. Part A Project Name: .... Montrachet . Lots 21.23 ........................................................................................................................................................ Grading/Erosion Control Permit #: Location of Land -disturbing Activity APPROX. 862 Montrachet Ct., Lewisville, NC 27023 Latitude:.. 36.096997...................................................................-80.463228 Longitude: Approximate Date that Land -disturbing Activity will Commence: , 04/01/2022...................................................................................... Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision KI Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 72.135 5.598 ...................................................... Acreage to be Disturbed:................................................................... Grading/Erosion Control Permit Fee: $ 1.652.00 Person to contact should Erosion Control related issues arise during land -disturbing activities: JUSTIN MENDENHALL Justin@ardenhomes.com Name: ...................... ............................................ . ............ Email: ...................................... ............................................................................ Office Phone:... (336) 659...9503.......................N/A........................................ .........N/A...... . Mobile Phone: Fax #: Landowner of Record: (use blank page to list additional owners if needed) 5865-87-0821, 5865-77-8760, 5865-77-7633 4435 021 ParcelPIN#:.................................................................................. Tax Block #:.................................. Tax Lot #:................................... Name...PM DEVELOPMENT LLC.................................................................................................................................................................. StreetAddress/PO Box: .....PO Box 5323........................................................................................................................................................... Winston Salem, NC 27113 City/State/Zip Code: .... I ........ I ........................................ ......................................................................... ...................................................... (3 Office Phone:. ..........36) ...659-9503 ..................................... Mobile Phone:........N/A .............................................. Fax#:...........N/A ...................................... Grading Contractor Information: (if known at time of submitting the Erosion Control Plan far review) Value of Gradin $ gContract: N/A N/A ................................................... City of WS Contractor 1D#:......................................................... ......... N/A N/A Name of Grading Contractor: ......................................................... ................... NC License#:................................................................ Contractor Contact Person: ........................................ N/A N/A ......................................... Contact Phone:............................................................... StreetAddress/PO Box: ............N/A .................................................................................................................................................................. City/State/Zip Code. ..................N/A.................................................................................................................................................................. Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional person(s) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm PM DEVELOPMENT, LLC PO Box 5323 StreetAddress/PO Box: ........................ .........•------------....................................................... City/State/Zip Code: Winston Salem, NC 27113 (336) 659-9503 N/A ...............................• ----............N/A............------•---.......... OfficePhone: ................................................... Mobile Phone: ........................................... I .......... Fax #:................................................. If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: ..N/A ................................. I............. .......................... ... ................... -•--•--............................... .... StreetAddress/PO Box:.,.,, ............................... _ .................................. City/State/Zip Code: ................. _ ...................................... ..........................................................•-------------......................... OfficePhone: ....... ............................. ............. Mobile Phone:.....-----............................................ Fax #. .................... ............................. If the financially responsible party is a partnership, provide information for each General .Partner: (use blank page to list additional partners if needed) Nameof Registered Agent:... N/A...................................................................................................................................................................... StreetAddress/PO Box: ....................................................................................................................................... City/State/Zip Code: ........................................... ......................................... ............................. ...... ................................... OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:...---........................................... 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 their attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with 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. STUART C. PARKS Typeor Print Name: .......................................................... _ ..................................... _ ...................................................... MANAGER Titleor Authority: ........ •.................................................................................................................................................. Signature: .................................................................................................................... Date:... f Q-........... I, ....... .�. .... .1.............................................. . a Notary Public of the County of .„ ;�J !J. ...................... State of......N..0 ................................ . do hereby certify that ...... ail. ..%X.A .......................... , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my hand and notarial seal, this ..................1 ``.............................................. day of ....1WAO—A- ............................ 20 .. •> Notary Public Name: ... -- `�: .. .......... Notary Public Signature: .. ........ .. ....... ......... My commission expires: ...... �J..:.:... "1....................... .-._ Elyse Howlett �? NOTARY PUBLIC _.� Davie County, NC My Commission Expires March 07, 2024 Notary Seal