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Home My WebLink AboutNCC222161_FRO Submitted_20220613City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC:` 27101 MIS1011601P10 Mailing: PO 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 part of a larger common plan of development exceeding these thresholds, before this forth and an acceptable Erosion Control Plan have been submitted, reviewed, and approved by the City of Winston-Salem Erosion Control Division and a Grading/Erosion Control Permit has been issued. Please type or print. Please place "NIA" in the blank space if not applicable. Part A Cadence Ph 1 Project Name:........................................................................................................................... ........ Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land-disturbingActivi N. Church St ty:.......................................................................................................................................................... Latitude: ................... N. 20.0.1..................................................... I.,oltgitude:....... -79:786.5................................................................. Approximate Date that Land -disturbing Activity will Commence:.................. Purpose of Grading: ❑ Commercial W Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 27.54 Acreage to be Disturbed: 14.20 Grading/Erosion Control Permit Fee: $ .................. ................ Person to contact should Erosion Control related issues arise during land -disturbing activities: Will Derrjckson i wyd.Qrl:i.rK5.Qn, g. Name:.................................................................................. Email I?141f.! 4:.r,9ill................................................. Office Pltone:. 336-231-6767 Mobile Phone:....336-979,4054 Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #:....... 5892-22-0649:000................................. Tax Block #:.................................. Tax Lot #:................................... Clayton Properties Group, Inc. dba Mungo Homes Name: .................................................................................................................................................................................................................... StreetAddress/PO Box:...221 Jonestown Road.................................................................................................................................... City/State/zip Code:... Winston-Salem:..NC 27104............................................................................................................................. ............. . .... ... 336-765.9661............... Mobile Phone....................................................... Fax #:................................................. Office Phone:..... Grading Contractor information: (ifknown at time ofsubmitting the Erasion Control Plan,for revietit) Value of Grading Contract: $................................................... City of WS Contractor ID#:...........82093......................................... Name of Grading Contractor: ............................................................................. NC I.,icense#:........ 5.1.390.......................................... Contractor Contact Person .. Contact Phone: 336-979-4 54 ......WIII ...Derrickson............._....,....,....,............................ 0................................. .... .. .. . .. .. Street Address/PO Box: ............ 221 Jonestown Road ...... ....................... ............................................................................................. City/State/Zip Code: ..................Winston-Salem, NC 27104.....................................................................................................I....... Part B Person(s) or firms who are financially responsible for this land -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:..,.,. .... Clayton Properties Group, Inc dba Mungo Homes Street Address/PO Box:........... 221 Jonestown Road................................................................................................... City/State/zip Cock: Winston Salem, NC 27104 .................................................................................... ............................... Office Phone 336-765-9661 ..... Mobile Phone'................................................................................................. Fax #:................................................. If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent:......................................................................................................................................... StreetAddress/PO Box:.............................................................................................................................................. City/State/Zip, Code: ... ............................................................................................ .......................................................... OfficePhone: ................................................... Mobile .Phone:...................................................... Fax #:................................................. If the financially responsible party is a partnership, provide information for each General Partner: (use blank page to list additional partners if needed) Nameof Registered Agent:................................................................................................................................................................................ StreetAddress/PO Box: ................................................................................................................................................................................ City;'State/Zip Codc:.............................................................................................................................._............................ Office Phone: ..... ............................................. Mobile Phone:...................................................... Fax #:................................................. 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 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 corrected information should there be any change in the information provided herein. Will Derrickson Typeor Print Name: ........................................................................................................................................................... Land Development Manager l'itle or Authority:............ ....... ............................................................................... ......................................................... Signature:........,.................................................................... Date: ... ........ 6/8/2022........................................ ....�(T.....�......................................... . a Notary Public of the County of...�,�..�t..V)k. i- ........... State of .................................................. . do hereby certify that .IJN-�.! .....-... E YT.Z�j�7 f ,appeared personally before me this day, and being drily sy{orn, acknowledged that the above form was executed by hinv'her. Witness my hand and notarial seal, this. ..................... U......................................... I...... day of ........ n.5'....................................... , 20 ad. i Notary Public Name: ................... .. .......................... Notary Public Signature: ............................................ My commission expires: .............I........1 ...� ... .ff CONNIE A. ADER NOTARY PUBLIC Davidson County North Carolina My Commission Expires 04/05/2025 Notary Seal