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Home My WebLink AboutNCC215176_FRO Submitted_20210914STORMWATER/EROSION CONTROL DIVISION 100 East First Street, Suite 328, Winston-Salem, NC 27101 Financial Responsibility/Ownership Form Erosion Control Ordinance No person may initiate any land -disturbing activity exceeding 20,000 square feet for a single-family dwelling or 10,000 square feet for any other purpose, before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Erosion Control Section of the City of Winston-Salem/Forsyth County Inspections Division. Please type or print. If a question is not applicable, please place "N/A" in the blank space. PART A Project Name: Juniper Glen - Lots 1, 2, 3, 6, 10 and 11 Permit# Location of Land -Disturbing Activity: Peace -Haven- Road,- Winston-Salem,- NC -------------------------------------------------------------------------------------------- Latitude 36.0771 L-ongitude-80,3538 Approximate Date to Commence Land -Disturbing Activity'September 2021 ---------------------------------------------------------------- Purpose of Grading: Commercial Residential Multi -family [—]Other (No development proposed) F,411esidential Single Family lot Residential Single Family Subdivision Total Site Acreage: 0_75----------------- Acreage to be Disturbed: ------- Permit Fee: Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name -Justin- Mendenhall -rou ---------------------- E-mail address g pustin thearden .com -------------------- --------------------------------------------- (336) 442-1225 Telephone -------------------------------- Cell #----------------------------- Fax # ---- Landowner of Record (use blank page to list additional owners): 253 South Peace Haven, LLC (336) 659-9503 --------------------------------------------------------------- ---------------- -------- Name Owners phone # Name P.O. Box 5323 --------------------------------------------------------------- ------------------------- Street Address/P.O. Box Street Address/P.O. Box Winston-Salem, NC 27113 --------------------------------- City/State/Zip Code -------------------------------------- City/State/Zip Code ----------------------- Owners phone # Tax Block #: 3908 Tax Lot #: 1 2'3, 6, 10 and 11 Zoning:RS9Zoning Approval: ------------------. -' - --------------. ------------ ------ PIN: 5894-99-8667; 5894-99-8661; 5894-99-8556; 5894-99-8430; 5894-09-0604; 6804-09-0700 Contractor Information Required Prior to Permit Issuance North Carolina State Law requires that contractors be licensed to perform work valued at $30,000 and higher. All contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. Value of Grading Contract Name of Primary Applicant (Grading Contractor) Street Address/P.O. Box City/State/Zip Code City of W-S Contractor's ID # Contractor's N. C. License Number Contact Person for Contractor Contact Person's Daytime Phone Number PART B I. Person(s) or firms who are financially responsible for this land -disturbing activity (use blank page to list additional persons or firms). Contractors are not considered financially responsible for property not under their ownership. 253 South Peace Haven, LLC --------------------------------------------------------------- --------------------------------------------------------------- ame of Person or Firm Name of Person or Firm P.O. Box 5323 ------------------------------------------------------------ - - --------------------------------------------------------------- Street Address/P.O. Box Street Address/P.O. Box Winston-Salem, NC 27113 --------------------------------------------------------------- City/State/Zip Code City/State/Zip Code (336) 659-9503 ----------------------- aytime Telephone # Daytime Telephone # 2. If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. --------------------------------------------------------------- ---- ----------------------------------------------------------- ame of the Registered Agent City/State/Zip Code --------------------------------------------------------------- --------------------------------------------------------------- treet Address/P.O_ Box Daytime Telephone # 3 -ribs-Eit cjaUy_Iespsl 4Ugh pmly is a partnership, give the name anWd&ss.Qf_eachS.renerdl.Parinerize blank page to list additional partners). Name of the General Partner --------------------------------------------------------------- Street Address/P.O. Box City/State/Zip Code ------------------------------------- Daytime Telephone # ------------------------------------------------- -------------- Name of the Genera! Partner --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code ----------------------------------- Daytime Telephone # 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 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. 253 South Peace Haven LLC uart Parks Manager _____________________________________________________________ ype or Print Name Title or Authority ----------------------------- --------------------------- "� ------------- Signature Date ------------------------------ Date I IQ 14C-L L:�id_CLI----------------- , a Notary Public of the County of '----- State of North Carolina, do hereby certify that 5 appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this c3{2-_day of __fLA&�_wsf ____--_--� 20 . �� - - - ----------�------------------------------------------- My commission expires: g a0a I ------ NOS lic TONYA L. WARD Notary Public, North Carolina Cabarrus County My commission Expires Oclober 28, 2021