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Home My WebLink AboutNCC220250_MODIFICATION Supporting Documents_20221010 (2)City of Winston-Salem Field Operations Department I Erosion Control Division UV Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 NS1110•SilleM 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 form 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 "N/A" in the blank space if not applicable. Part A Project Name: ..... OId Mill Subdivision ...................................................................................................................................................................................... Grading/Erosion Control Permit#: Location of Land -disturbing Activity "0" Ar, , ..NC ..............Drive..............Clemmons........................................................................................... .. .. den .. .. .. .... ... ... ..... .. . .. ... Latitude: ... 36:0180 ..........................:. ........................... Longitude: .:0.3692 ............ ..................... ............................................. Approximate Date that Land -disturbing Activity will Commence: September 2022 Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ® Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 41.06 ....................................................... Grading/Erosion Control Permit Fee: S.................................. Acreage to be Disturbed: 23: 32 ...................................................... Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: ... Todd Isenhour Email:... toddisenhour@isenhourhomes.com ............................................................................................... Office Phone: .(.336) 345.1214 Mobile Phone: Fax #:....................................................................................................... Landowner of Record: (use blankpage to list additional owners if needed) 5892-57-0376 (Portion ofl; 5892-57-7962 (Portion oft ParcelPIN#:.................................................................................. Tax Block #:.................................. Tax Lot #:................................... Name: ,Old Mill1. Su.bdivision.., LLC.......................................................................................................................................................................................... Street Address/PO Box: 3411 Healy .. Drive . ............ , Ste .. A ............................................................................................................................................... City/State/Zip Code: Wl gn.Sa.lem....... , NC 27103............................................................................................................................................................ Office Phone:.�336) 345.1214 Mobile Phone Fax # Grading Contractor Information: (if b7orrn at tune of submitting the Erosion Control Plan. for review) Value of Grading Contract: S................................................... City of WS Contractor ID #:.................................................................. Nameof Grading Contractor: ............................................................................. NC License#:................................................................ Contractor Contact Person: .................................................................................. Contact Phone:............................................................... StreetAddress/PO Box: ..................................................................................................................................................................................... City/State/Zip Code: ........................................................................................................................................................................................... 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: Old Mil.l..Subdivision.., .LLC. ................................................................................................................................... Street Address/PO Box: 3411 Healy ..Drive, . Ste .A ............................................................................................................................ City/State/Zip Code: Vlfnston. Salem...,..NC...27103.............................................................................................................................. Office Phone:.(336) 345-1214 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: .................................................................................................................................................. Street Address/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 Code: ........................................................................................................................................................... OfficePhone: ................................................... 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. Type or Print Name: Old Mill Subdivision, LLC (Todd Isenhour) ......... ................................................................................................................... Title or Auth : „ ..a er Signatur ...... Datc: I . ............. (:Dn':nm... ................................................ , a Notary Public of the County ................................, State of ..Nmth... (:i K01i.00.............. . do hereby certify that ..K ,..►.Udd.. �1l�llY.................................... , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by himAwx. Witness my hand and notarial seal, this 2d....... ..... ............................................. I .... I..... day of t?CJcb=.................................................. 20 a % C Notary Public Name:...?`C.(hllp,...H..G4�.l.�GY?........................ Notary Public Signature: ............ : U ; My commission expires: ...lAla.I..aI4.Ak)A:1.............................. ��•,N�til$ Z= 1 �: ,•,,,�C