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Home My WebLink AboutNCC220913_FRO Submitted_20220228STORMWATER/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 Barrow Farms -Phase 1 & 2 Project Name: __ _____________ Permit # ----------arm--------e------2---------------------------------------------------------------- Location of Land -Disturbing Activity: Latitude 36.1815 Longitude_-80.1139 Approximate Date to Commence Land -Disturbing Activity: DECEMBER-2021 Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) Residential Single Famil lot 9 Residential Single Family Subdivision Total Site Acreage: Acrea a to be Disturbed• 26.66 Permit Fee: $6,096 ------------------------------------------------------------------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Will Yearns _____--_- E-mail address wyearnsClMy-granvillehome.com ---------------------------------- Telephone 336.202.8514------------- Cell # Fax # ----------------------------- -------------------------------- Landowner of Record (use blank page to list additional owners): CYD-Barrow Farms LLC 336-202-8514 Will Yearns 336-202-8514 ----------------------- ---------------- ---------------------------------------------------------- ------ ------ --- ---- ---- --- Name Owners phone # Name Owners phone # 7349 W. Friendly Ave. Ste. H --------------------------------------------------------------- Street Address/P.O. Box Greensboro, NC 27410 CW;i-- te/Zip-Co e ----------------------------------------- CityJState/Zip Code Tax Block #: 5223 Tax Lot #: 009M 7349 W. Friendly_ Ave. Ste: H --------------------- ------------------------ Street Address/P.O. Box Greensboro, NC 27410 --------------------------------------------------------------- City/State/Zip Code Zoning: RS_ 30---------- Zoning Approval: Contractor Information Required Prior to Permit Issuance North Carolina State Law requires that contractors be licensed to perform work valued at S30,000 and higher. All contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. S 150,000 Value of Grading Contract City of W-S Contractor's ID # TBD Name of Primary Applicant (Grading Contractor) Contractor's N. C. License Number Street Address/P.O. Box City/State/Zip Code 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, CYD- Barrow Farms, LLC ------------------- o-r- F-i-r-m of Person or Firm _7349 W. Friendly Ave. Ste. H ---------- ------------------------ Street Address/P.O. Box Greensboro NC 27410 --------- - - - ode--------------------------------------------- City/State/Zip C 336-202-8514 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. --------- - -------------------- Nameof---------------------------------------------------- City/State/Zip Code- ------------------------------------------ --------------------------------------------------------------- S-r-eet--A--d-d-r-e-s-s-/-P--.O--.--B-o-x------------------------------------- Daytime Telephone # 3.-1f ibe-CumciaUy-tespDJl. dO.p pAny is a partnership, give the name and&ddzeust£cvll. ien pJ-e=r,r We blank page to list additional -p-a-r-t-n-e-r-s-).1 I f r fd�3--'--►' - �----------- =---------------- -I -G-f----- ----------------------------------------------- Name ofhe- G--en-eral - Partner -------------------- -N-a--m-e of tpe General Partner 073�q '= S�ci to H nf Pew, Dul ��--------L----=----S-i-------- Stree-Addres-s-/�P- .O-.--B-o-x--------- Street Address/P.O. Box --- --- �---------"-----N� d 7' ] -- '� �`----x':----%1------ �= tU ----------------- ---------------------------------- City/State/Zip Code City/State/Zi Code Daytime Telephone # 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 the be any change in the informatioovided herein. -�� r -----��'-� ��-----Q-_�'�c��mS------------------ F ----------- ---- ------------------------------------------------ Type or Print Name ----- Title or Authority ----------- - - ----- A--- -- _ _ ____ Signature Date 1, ------ -- _-- C- (_�: _-- , a Notary Public of the County of __ - State of North Carolina, do hereby certify that 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 --)+�-\- day of /� j I XC_'_L_9_ --------------- ------------------- ----------------- My commission expires: Z Notary Public 71110H. CHURCH ARY PUBLIC TH COUNTY, NC