HomeMy WebLinkAboutNCC231280_FRO Submitted_20230523 City of Winston-Salem Field Operations Department Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
Wlnslon;salllui 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 Hanes Lake Phase 2
Project Name:
Grading/Erosion Control Permit#:
2750 Spicewood Drive
Location of Land-disturbing Activity:
Latitude: 36 deg 9 min 0.36 sec Longitude: -80 deg 21 min 44.63 sec
Approximate Date that Land-disturbing Activity will Commence: Spring 2023
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ® Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
185.30 45.34 Acres
Total Site Acreage: Acreage to be Disturbed:
Grading/Erosion Control Permit Fee: $ 8,040
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Will Derrickson wdernckson@mungo.com
Name: Email:
(336) 765-9661 (336) 979-4054
Office Phone: Mobile Phone: Fax#:
Landowner of Record: (use blank page to list additional owners if'needed)
5897-74-3860,5897-75-1832.5897-85-0917 4633
69,133,136
Parcel PIN ( Tax Block #: Tax Lot#:
Clayton Properties Group, Inc
Name:
Street Address/PO Box 221 Jonestown Road
City/Blatt/Zip Code: Winston-Salem, NC 27104
(336) 765-9661 (336) 979-4054
Office Phone: Mobile Phone: Fax#:
Grading Contractor Information: (if known at time of'submitting the Erosion Control Plan for review)
to be determined TBD
Value of Grading Contract:S City of WS Contractor ID II:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/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 fines if needed) ***Contractors are not considered financially responsible for property not under their ownership***
Clayton Properties Group, Inc,
Name of Person or Firm
221 Jonestown Road
Street Address/PO Box:
Winston-Salem, NC 27104
City/State/Zip Code:
(336) 765-9661 (336) 979-4054
Office Phone: Mobile Phone: Fax
If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered Agent.
Street Address/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:
Street Address/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 should there be any change in the information provided herein.
DkType or Print Name: antstrSu�
Title or Authority: 4s51-. �Ceref.-J/
Signature: CJV Date: 3//)/'t
m 1 h kc hol y a Notary Public of the County of ..
State otalhearMAC:k ,do hereby certify that.Sl4�t Sft41rrI FT-SOY") , 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 I r day of ..... .1 ..� ,2023
Notary Public Name: *`ri " 'I` L. 01 C-�`�]
KIMBERLY L.NICHOLS
Notary Public Signature: 11 NOTARY PUBLIC
My commission expires: 1 2 6 Q 1 2e2�"] r S COUNTY
Nn
A�F NORTH CAROLINA