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Home My WebLink AboutNCC223009_FRO Submitted_20220824City of Winston-Salem ReW Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328,Winston-SalemNC 27101. WMM-Sft 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 Singh'-Farnily 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: Havenbrooke Subdivision .............................................. -- .................... ....... . . .... . . . . ..................... . ....... . ... . ... . .. . ................... . ... . ......................... GradinglErosion Control Permit #: Location of Land -disturbing Activity: Church Rd. (across from existing Thelbe Lane) ................ . ........................... Latitude: ............. 36.175744 Longitude: -80.046372 .. . ......... ................................. ...................................................................... ..... Approximate Date that Land -disturbing Activity will Commence: .................................... September 2022........................................................................ Purpose of Grading: F] Commercial ®residential Multi -family Fx1 Residential Single-family Subdivision 0 Residential Single-family LobUts 171 Other Total Site, Acreage: ...... +/-74.97 .......... Grading/Erosion Control Permit Fee: $ ..... 6500-00 .............. Acreage to be Disturbed: . . ....... /-29 . . . I .............................................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: ..... Greg Garrett .................................. . ..... .... . .... Email: ...... braxton.reanddev@gmail...com ........ . ........................................... ... ..... ............. . ........... . . .. ............ ............ ... ... Office Phone:... 336-399-7197 ..................... Mobile Phone . ..... 336-399-7.1.97 ....................... Fax ........................ . .......... . ....... . .... Landowner of Record: (use blankpage to list additional owners if needed) 6898-04-3849.000 5417 2J ParcelPIN #: ............................................................................ ...... Tax Block 4: .................................. Tax Lot 4: ................................... Name: .......... Branton .Rea.I.Estate-an.d.Development.Co...,..LLC, ............... ....... . ............ .... .. ......................... ..... ....... 6420 Hampton Knoll Rd. StreetAddress/PO Box: ........................... . .............. . ..................... . ..... . .......... . .... . ................... . ................................... . ............... . ............ Clemmons, NC 27012 City/State/Zip Code: .................. . . ...................... . ............................................................................................................................................ Office Phone336-399-7197 ....... Mobile Phone.............336-399-7197 ............ ..I. . ... .................... ................ Fax #: ................................................. Grading Contractor Information: ff known at time ofsub mfitting the Erosion Control Plan for review) Value of Grading Contract: $ ...... $250,000 ........................... City of WS Contractor ID #: ... . ............................................................. ................. Name of Grading Contractor: ..§pft!9!nuEA§p 'ainhour.Gradipz. Inc .... . NC License #: .............. .................................................. I ........... .......... . ...... Contractor Contact Person: ... Jeff . ........ . ...................................... Contact Phone: ... 336-983-21.20..... ................................. . . .. .......... . ................... Street Address/PO Box:... � . Box 2127 ....................................................................................................................................................................... City/State/Zipr Code:..., King,..NC 27021 ............................................... . .............................................................. . ...................... . .......................... ................ Person(s) or firms who are financially responsible fax this land -disturbing activity; (use blank- page to list additional person(s) orfinns if needed) ***Contractors are not considered financially responsible forproperty not under their oNvnmhip*** Name of Person or Firm: ...... 8 . raxton . Real I Estate . and Development Co., . LLC ................. .................................. ...' ............ .. ......... ..... - .......... ...... ........... ............ ...... 6 Street Addiess/PO Box..-... ........420 ... Hampton Knoll Rd....... ...... ...... ....................................... .............. ........................ I .......... City/State ,`Zip Code . ...... Clemmons,_ NC 27012 ........... .............................. .............. ....................................... .......... ........... ----- ------------- 336-399-7197 336-399-7197 Office Phone: ........................... ..... .... Mobile Pho -ie . . ......... . .. . ...... — Fax #: ......... . ........... . . ...... . .......... If the financially responsible party is an out-af-stabfirm, provide information for the in -state registered agent: Nameof Registered Age -at% ----------_-_- __ ............... ...................................................................................................... StreetAddress/P0 Box.._._....._ ..................................... ----- ......................................... .......... ................. City/StateiZip Code: ....... - - ------------_ _ ........ .............. Office Phone: Mobile Pho 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 . ... . ............... . ..................... . .... . ....................... . ........................ ............. ......................................... . ................. Street Address/PO Box: City/State/Zip Code: .................................................... ............................................................................................. Office Phone: Mobile Pboit_-- Fax #_- The above information is uue and correct to the best of my'mowledge and belief and was provided by me under oath- (This form must be signed by the financially responsible person, if an h tdividmL or their aftaracy-in-hct, or if not an individual, by an officer; director, partner, or registered agent with authority to execute insmwxmts for the financially responsible person_) I agree to provide corrected information should thet-c be any change in the infurmation provided herein. TypeorPrint Name: ............................................ ___ ............. ................. ...... ........... TitleorAuthon _ ... & .......... . .......... ................. ..................... ...... _ .................. ........................ ............... Signature:...... ya__ �_ ..... . ............ K ........ . ........... . ................... ........ . ..... .... Date: . D__ ........................ SV&Ayw,7 L County of . ....................... ............ a Notary Public of the Cou ............. I .......... State of ......... h- C_ &A Ire- ...... ........ ........................... . . do hereby certify that ......... G appeared personally before me this day, and being duty sworn, ack 3owledged that the above form was executed by himtheL Witness my 21'_4h . f4__ . . ......... . ....................... . 20 :22- hand and notarial seat, this ___ .... . ...... . . .. . .. .................................. day of * ...... Notary Public Name- -she I Notary Public Signature: mycommission expires, SHANNON L BROAI NAX NaFARY pUBLI Forsyth county, North Carolina my Commission Expires 121041 1 2024 ofaf-l� Seal