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Home My WebLink AboutNCC230498_FRO Submitted_20230224City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328. Winston-Salem, NC 27101 11l11511111$81PIll 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/Erasion Control Permit has been issued. Please type or print. Please place "N/A" in the blank space if not applicable. Part A Project Name:... Sawmill Creek Phase 1 ............................................................................................................................................................................... Grading/Erosion Control Permit #: Location of Land -disturbing Activit • 6853-55-3129 Latitude: 36.0405°................................................................... Longitude:-80.1680° ................ .....2................................................................................... Approximate Date that Land -disturbing Activity will Commence: 11/1/20.22.. .......................................................................................................... Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision Residential Single-family Lot/Lots Total Site Acreage:. �.61AQ..................................... Grading/Erosion Control Permit Fee: $.................................. ❑ Other Acreage to be Disturbed:.. 2.2...8.0 .................................................... Person to contact should Erosion Control related issues arise during land -disturbing activities: Name:.... Kat Lyons E,nail:.....kat:I�rons a�leoterradevelopment; com ...... ............................ Office Phone n/a Mobile Phone. 336-682;1414 Fax ..................................................................... .............. Landowner of Record: (use blank page to list additional oivner s if needed) Parcel PIN #:.•6853-55-3129 .. Tax Block #: Tax Lot#:................................... .............................................................................................. Narne: •.. LeoTerra Sawmill LLC ........................:............................... ....................................................... .................................................................................. Street Address/Po Box:.. 110 A Shields Park Drive .............................................................................................................................................................. City/State/Zip Code:.... Kernersville, North Carolina 27284 ........................................................................................................................................................................... 336-279,.7280................. Mobile Phone Office Pllone:..................... Fax #:................................................. Grading Contractor Information: (if knoivn at thne of submitting the Erosion Control Plun 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: .LeoTerra..Sawmill..,..LLC.. .................................................................................................................................. Street Address/PO Box: ..110-A Shields..Park..Drive .......................................................................................................................... City/State/Zip code:.. Kernersyil... NC 2728.. ............................................................................................................. Office Phone:.336,..................... 279-7280 Mobile Phone:...336-486.3653 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:...................................................... Faxr:................................................. 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 tile under oath. (This form Hurst 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: ... Cki.rl. a (-� .tr-....... . �. ✓1.5 Titleor Authority' .... SL''►...................................................................................................................... 202Z Signature: ...... ................................................................................ Date:.......,J.. mot.,.......................... I . ................ ......... �..a r. ............ , a Notary Public of the County of ....... "t.V..I.I' !' ................. State of .... /�f f h... .. <<. . , do hereby certify that ....... ..`,i4la..'.\..5..... , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my hand and notarial seal, this.................L...L..�......................................... day of .......4.. .�.." '; r!!)..�,�- ............... 20 .zZ Notary Public Name: .. .. '"` ...... ' 4 �;� tasloq ,•O,�'y Notary Public Signature: ...�� . ............. _ WOTARy .... _ q;?7:.6 In,G UBL1G : �2,aMy commiss►on expires: .............1......... . ((( ..-N, rr Sect' .,��+O�p COS•"•