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Home My WebLink AboutNCC231036_FRO Submitted_20230417 City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street,Suite 328,Winston-Salem,NC 27101 44111111111Silll'lll 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"NIA"in the blank space if not applicable. Part A Bell West Ph 1 B ProjectName:..........I........................................................................................................................................................................................... Grading/Erosion Control Permit#: .................................................................................................................................................................. Location of Land-disturbing Activity: Bell West Drive: Kernersville NC 27284 .. ....... ............ ............ ................ ..... ....... Latitude: 36;100071................................................................. Longitude: -80;14766,1................................................................... .... ............... Approximate Date that Laud-disturbing Activity will Connmence: ............................................................................................................ Purpose of Grading: ❑ Commercial ❑ Residential Multi-family N Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑Other Total Site Acreage: 38.9 ........ Acreage to be Disturbed' 22.3 .............................................. . ................................................................... Grading/Erosion Control Permit Fee: $ .................................. Person to contact should Erosion Control related issues arise during land-disturbing activities: Name: Will Derricks.... ............................................ Email: wderrickson@mun�o:oQm....................................................... Office Phone: .336-231-6902 Mobile Phone 336-231-6902 Fax#:................................................. Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN#:.. 6568-16-8518, 6568-16-4978 Tax Block#: ........5341............... Tax Lot 4:....................... Nauue: ...Braxton.Real Estate R Developmet CompanX:..LLC:................................................................................................ ......................... ............ .............. StreetAddress/PO Box:642Q Hampton Knoll Rd.............................................................................................................................................. City/State/Zip Code:...Clem m on...N C 27012....................................................................................................................................... OfficePhone:....336-399-791.7............... Mobile Phone: ...................................................... Fax#:................................................. Grading Contractor Information: (if known at time ofsubmitting the Erosion Control Plan for review) Value of Grading Contract: $ ................................................... City of WS Contractor ID#: .................................................................. Naiveof Grading Contractor: ............................................................................. NC License#: ................................................................ ContractorContact Person: .................................................................................. Contact Phone: ............................................................... Sheet Address/PO Box: City/State/Zip Code: ........................................................................................................................................................................................... Part B Person(s) or firms who are financially responsible for this land-disturbing activity: (rise 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 Finrr: .ClaytOn PfOiJeftle5 Gft7U� lf1C r.................... Street Address/PO Box: .221,Jones.tpWCI„Rd. City/State/Zip Code: .Winston-Salem NC 27104 ................................................................................ Office Phone: 33.6-231. . -6902. .................. 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. ....................................................... .................................................................................................... Office .................................................Phone'. .. 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) Name of Registered Agent:................... StreetAddress/PO Box:...................................................................................................................................................................................... City/State/Zip Code: ...................................................................................... .............................. 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 shou ld there be anychange in the in{f(onnfationprovvided herein. Type or Print Name: .. 9.....iY..t..T4.a.I.4�So. ................................................. .. ............................ Title or Authority&kol�, Cl. ,!.) '`..... ...[..F-4�L ...1!!V.St!t.! ..1.��1ti!lll.... . Signature: ......... . Date: . Sal . 1, ..... �......b..-�r� N1. ......................... a Notary Public of the County of... 0 L....`...."............. , State of .....vl.Zl.1.. 1 do hereby certify that.f..�M..ms...N..: 1..+..1.4�f.�?.!.1.............. appeared personally before me this day,and being duty sworn,acknowledged that the above form was ss]executed by him,'her. Witness my hand and notarial seal,this .....................2.5........................................ day of ................/...:.'..a r ..................... ,20.z.3' .....i... ... Notary Public Name: . .. ....V:.'...!k KIMBERLY L.NICHOLS Notary Public Signature: ... . ��&Aos NOTARY PUBLIC . .. ....... . �' 2O Z7 FORSYTH COUNTY My coumnission expires: ....................................... ...................... STATEOF NOIRTH CAROLINA