NCC231081_FRO Submitted_20230502

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City of Winston-Salem Held Operations Departtrtnerit Erosion Control Division •
tdj Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101 •
•
WlI1S11111iii F1l Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial ResponsibilityinymembirpFenn
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 pan 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 Gradirt/rri:sion Cont_oi Permit hest•^en iss ied. Please type or print. Please place"N/A"in the blank space if
not applicable.
PrtA ,1
Project Name...,3ko.6%NDA"L� Su$+��V'�St4 ?..... ........... .rE�!I/ z IQ0 E 4`rq,r
�
Grading/Erosion Control Permit#: E.t 2 1 O
Locatic. of Land-disturbing Activity: --P 0 C. V-q$ h-A3ra LE �R W ti1.a - 5 A 4,EA'1.
O
Latatttci.=;: ..,�.��...e.n a.�.�Q 1 . iLongitude: , ,ct�` � V3.5
Appro:x ir_mte Date that Lai:d••disturbing Activity will. Commence: .. 5 Q.%-5 ��.4 Z j
Purpos. of Grading:
❑ Commercial ❑ Residential Muiti-fan,il,, _Residential Single-family Subdivision
17
Residential !Iiiiole-family Lot/Lots 11 Other
Total Sic.Acreage 1. • Z'M Acreage to be Disturbed: 6 •5 S
Grading/Erosion Control Per lit Fee: S .4.� 5. .�: ...:...
Persoiit %,ic''l s oulQi S"o5ion Co"itroi rei2sted issues ar ;: urll T land-disturbing activities:
Name: .. IT.G.K. t.l,.l 1%-kl?. Email: M • Nts)f-Quy 1:.. CvM
Office 'horse: aS Mobile 1'.i:ione' . . Fax#:
Landowner of Record. (use blarxlc page to list additional owners ifneedea)
Parcel PIN#' k'ee!,5LA — 11 ' \ `A. Tax Block#: 8 L 6 Zo Tax Lot#: l.0 41
Name: .. ..................... CO-" 4 L L.C.
Street Address/PO Box: VO o K G\O 14.2 1
City/State/Zip Code:.. t
Office Phone: cA e6ik6 Z.ic Mobile Phone: Fax#:
Grading Contractorinformation: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: $ City ofWS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: ... Contact Phone:
Street Address/PC' Box:
City/State/Zip Code:

,
Part B
Person(s) or firms who are financially responsible for this iand-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: t'sk k"CL-.4- IA CCCK GA— U.,C--
,
Street Ad.dress/P0 Box: ?C' B 0 Y- ck 0 L\ Z 1
City/State/Zip Code: .RAL-ek C‘ 1-1. i QC- 21a15- ,
Office- Phone. Ct‘41,— (a 46—`1.2-(-{C Mobile Phone: Fax#:
If the financially responsibk gsty is air ont-of-s tate linri,proviide information for the instate registered agent:
Name of Registered Agent.
Street Acidress/PO Box.
City/SiL. ip Code:
Office Pli3n.e. Mobile Phone' Fax#:
If the financially responsible party is a partnership, provide information for each General Partner:
(use blardc page to list ad.ditional partners if ncedcd) '
Name c Registered Age n
Street p..ddiCSSTPO Boy'
City/SNi.-uip Code:
Office 7)H.'" ' Mobile Phone' Fax-4.
The abcv information is true and correct to the best of rry Imowledge 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
correctc,( iDfonnation should there be any change in the n.forniation provided herein.
IA tic Lk-t;GC, .0 NkV le
Type Of Print Name: M 0-1
Title or Authority:
------
....,----
Signature: -.-•"-' ' Date: Z 125 I ZO 2-a
..----'
I, .C.-2/11. j ( -4- , a Notar,7 Public of the County of
State of A/Aftil COArteevtlai, ,do hereby certify that 4-1/.4.42-e-4 Aftwc,pt. ,appeared
personally before me this day,and being duly sworn, acknowledged that the above form was executed by hindher.Witness my
hand and notarial seal,this 4 6 day of ,t,
O.. --- , 20 ..I.P
outtittamoli
e vx- 4,04, i
. .:, .
_ _
Notary Public Name: CA ii5 ei el /1 t•Vvi -e.?(-el"
-...=f CHRISTIAN J.WHEELEO:
FE. =
Notary Public Signature:
CAR-(4. 1in 0 c 14,4t,tait = Foisyth county ....
= My CommisSion ExpiraS
1---5:, May 18,2026 Zz .
My commission expires: ppr AV y Weal 0,,„7-
/41/4011il Igo°