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Home My WebLink AboutNCC215614_FRO Submitted_20211011STORMWATERIEROSION 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 "NfA" in the blank space. PART A Vernon Farms Phase 3, Sect. 1, Tract 1 & 2. Project Name: ----------------------------- ------ Permit #_ Location of Land -Disturbing Activity: Dumont Drive & Westhill Place ------------------------------------------------------------------------------------------------- Latitude 36.092705 Longitude-80.154349 Approximate Date to Commence Land -Disturbing Activity: ____ AuEst_15,_2018 Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot [ 9 Residential Single Family Subdivision ] Total Site Acreage: ____ 18.51 Acres Acreage to be Disturbed% 19.20 Acres Permit Fee: Person to contact should erosion and sediment control issues arise during land -disturbing activity: Barry Siegal bscholding@aol.com Name--------------------------------------------- E-mail address ----------------------------------- --------- 336-292-9010 336-587-3633 336-632-0207 Telephone-------------------------------- Cell # ----------------------------- Fax #--------- -------- .-------------- Landowner of Record (use blank page to list additional owners): Patterson Holdings LLC. ---------------------------------------------------�---------- --------------------------------------------- ---------------- Name Owners hone # Name Owners phone # P.O. Box 597 ----------------------------------- --------------------------------------------------------------- --------Add----lPStreet ressO. B-o-x - Street Address/P.O. Box Burlington,N.C. 27216 --------------------------------------------------------------- ------------------------------------------------------------ CitylStatelZip Code City/State/ZipCode 6855-84 9639 Tax Block #: 6855-74 Tax Lot #: 6798 - Zoning: __ RM8 S_______. Zoning Approval: 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 Dice. S 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 1. 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. . Sudbury Development LLC Name of Person or Firm P.O. Box 16168 ....................................................... Street Address/P.O. Box High Point, NC 27261 ....................................................... City/State/Zip Code 3369-292-9010 ....................................................... Daytime Telephone # Name of Person or Firm Street Address/P.O. Box City/State/Zip Code 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. Name of the Registered Agent Street Address/P.O. Box City/State/Zip Code Daytime Telephone # 3; If the financiallX responsible party is a partnership, give the name and.address of each General Partner (use blank page to list additional I.If th.e.fmancial.lv..r.espplis.i�l.e..pa ............................................. partners). •••.................••........•••...............••••••........•••••......................................................................................................:.............................................................................I................ Name of the General Partner Street Address/P.O. Box City/State/Zip Code Daytime Telephone # Name of the General 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 shout there be any cge in th ation provided herein. ................................................... .......................... .. ` .................................................................................................. Type or nt sme Title or Authority, ,............................. ................. .........o �-��..%.......................................................................................... Signatures-''~ Date I� -i t a Notary Public of the County of.1,�;•„.j•..... ,'��.., State of North Carolina, do hereby certify that '... Jam!.. {L-.1..........' .4 S,.�.....L............................................................................................................ 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 ' I •••___• day of ............ �`�"� ` 20....�... .. .......L....... ?�......... `�... ......................... ............................................................. 1. My commission expires: .............. �� ota blic ry ......................................................... Kelly M Hill Notary Public State of North Carolina Guilford County My Commission Expires