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Home My WebLink AboutNCC220737_FRO Submitted_20220215P City of Winston-Salem Meld Operations Department I Erosion Control Division Office: 100 E� First Street, Suite 328. Winston-Salem, NC27101 lflll5ltlll a 111 Mailing: PC) 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 pact 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-Salen-1 Erosion Control Division and a (;rading/Erosion Control Permit has been issued. Please type or print. Please place "N/A" in the blank space if not applicable. Cart A Idolwood Subdivision ProjectNanne:.......... ............................................................................................................................................................................................. Grading/Erosion Control Permit ii:.......................... ......................................... ...._... ........... -........................... -........................................... Location or'Land-disturbing Activity 0 Idols Road, Winston-Salem, NC I atitude: 86.0026 .... Longitude:-80.379$ Approximate Date that band -disturbing; Activity will Commence : 2//0, .....14........2....22 .................................................................... ......... Purpose of Grading: ❑ Commercial 1� Residential Multi-farnily ❑ Residential Single-family Subdivision ❑ residential Single-family Lot/Lots Total Site Acreage: _JAM ......... Grading/Erosion Control Pen -nit Fee: $.................................. ❑ Other Acreage to be Disturbed-, .......14 00................................................ Person to contact should Erosion Control related issues arise during land -disturbing activities: Name:.... WiII Derrickson.............I.............................. snail:......,................................................. Office Phcnne:....336 ; 231-6767 .............. 336-979-4054 ................................................................... Mobile Phone Fax ?: 1,andowner of Record: (use blank page to lisi additional owners if needed) 5892-22-0649.000 Parcel PIN #:........................... ....................................................... Tax Block #: .......... ........................ Tax. Lot ....... .................... ,..,. Clayton Properties Group, Inc. dba Mungo Homes Nann e:....................................................................................................................................................:..»......................I .................. I ...... I.......... Street Address/PC) Box....221 Jonestown Road.................................................................................................................I.................. City/State/Zip Cod e:...Winston-Salem:.N.C..27104............................................................................................................................. 336-765-966.1............... Mobile Phone:...................................................... Fax #:................................................. Office phone:..... Grading Contractor .Information: (tf known at tine of submitting the Erosion Control Plan for review) Value of Grading Contract: $................................................... City of WS Contractor IC) #:....... .... 820g3........................-.............. Nameof Grading Contractor.............................................................................. NC License #:........ 8.1..6............... I .... I .... I................. ... Will Derrickson............................................. ..... 3�N.- ?9-404 Contractor Contact Pet;son: Contact Phone: Strut Address/'PO Box ............. 221 Jonest..o.wn...Road....... .................................................................................................................... ................. .... City/State,/Zip Code: ..................Winston-Salem,..NC 27104............................................................................................................. Pat-t B Persoll('.) or firuls 'A ho are fill a "via I iY responsible for dais land -disturbing activity. (UW Wank page. lo I ig( additional 4*4( '0111VICRWS 1fC. D01 COIlSidel-01 fitnallcially ]-USPOII�;iblc fbi, properCy nm under 111cir 0waQtSkP*** Name, of Person Qr Hum .................................................... Strect Addres&TO Bov — ..... .2.21 . J,ofle's.town, .R.oad ................................... ........... ....................................... I .............. Winston Salem, NC 27104 ("ity/swicizip Code: ..— ...... ---- ............................................................................................................................ 0,111tv, phonc:.A36-231-..6745 ..... . ......... ............. ......... .... Mobile Phone: ... Fax 9-: .. . ............................................. If tilt, financially responsible party is an otAt-of-state firm, provide information for the in -stake registered agent: Nomeof Registered Agw�,nt:— .... .......................................................................................................................................... -,uect AddrQss/110 Box-1 ......... ........ - .......... Citv/slaw'zir Code� ........ ............. . ......................................................... Office pholle: - ....................... -- .......... ---- Mobile Phont; , .................. ... --- ............ ......... Fa'x #';— . ............... --- ......... If tile financially responsible party is a partnership,provide information for each General Partner: (use blank page to list. additional partners if nccdedl) MarieO'kegistered Agent.- 11 ... —1.1-1--- ....... ........ ...... ...... ....... -- ....... ..... ................... — ......... ...... ........... ...... ....... ,Yrect At dmislllo Box: ... . ..... ...... . ....................................................................................... . ..... ( I ' , ily/Statcl/Zip Code: ....................................-1-1 ....... I ......................................... I-- ................................ 4 ..................... Offic", Pholic: .......... ........ ......... ....... Mobile PlIone.- ..1-1.1-1 ....... , 111.1 ........ — Fax ......... - ........ -- ......... ......... Thi, above. iiifiormation is L-vw and comm to thu be,,M ot"nay knowledq�, and belief nod wms providod by irw uut4;r oath, Cy"his forni Must be signed by the fimillcially i'espunsible pensonif an jti(jividwd, or their aulorney-in-fiact, or if lotan h1dividw3j, by an officer, diroctor. , partner. or with audoxily to (=uuw for 111C financially vesjvnsiblc jwrson) f agre(to provide wri-ccted -Information should tl,erv. 1-cany change hi the infumiaLion proviei,, ] fict-cirt. "FyPe kir Print Milne,- — ..... Ponn.ie.Ader ................................................ . ...... .. .. .. ...... noc or At Operations Manager ... ............ .. ........... * ........... ................ . .................................................... . Date: —J ...... I . .......... An�''d.........�i`2....... ...................... a Notary Public ofthe County of ...... r4w.17,11 .... I ............ . State do hereby certify . . ..... . ............. . . 1ppeavA personally before taco 0)is day"Ind bcing duly svonl' acknowledged that the --bow f'onri was exemited by him/lier. a,Vitness 11)'v hand and notarial SUM, this ...........................4 v. ........ . ..... day kit ...... Y0114-4--20.2 - 2 ANGELO. HIATT ... Notary Public - North Carolina Forsyth Countryty MY Notary Public Signature, .... . I Mv coin miss ion eNj)irea. ........... .. . ... .. ................ Jvotary seal