NCC233313_FRO Submitted_20231107

City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street.Suite 328.Winston-Salem.NC 27101
ltill0.11$11111 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: ...1271,4 C/, CL E S -50/y/51.04/
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: Off 8RRO f/ L/Re LE L E4/CVIz_L£ N L
o if
Latitude: ,36 OZ S2 Longitude: .............��..........
Approximate Date that Land-disturbing Activity will Commence: 5.te�en&-k tz O2 3 — —~-
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family 11 Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑Other
Total Site Acreage: 33 ' '- Acreage to be Disturbed: 2• 7
Grading/Erosion Control Permit Fee: $ .t
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: V 1 L $ERO TH Email: V. Irv-/L'&�rj�u• /• �rn
Office Phone: Mobile Phone: . (33(,)..39.q—.221Y-1 1Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PSN#: — 2 7 7 S Tax Block#: Tax Lot#:...1 D/ JD
Name: __t:&40.7-H
Street Address/PO Box: 2 S II OL /VET c y w, eH RDA f)
City/State/Zip Code: W tip 3 1-0A/—J'4LE, r, 2 7/0lv
Office Phone: Mobile Phone-....(336) 3?f-.,22 aft Fax#
Grading Contractor Informnation:(i known at time of submitting tire
Erosion Control Plan far review)
lr
Value of Grading Contract:S f t`� 8E PE R i/�Etitv of WS Contractor ID#:
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
persoyrr[7eutiette4!ia.ate ttv:t,:,:::icterifinancially r spousibto.far ro crt.:not under heir own stnpas"
u{s)or firms t!x=_•iSr<jj d � .
Na!rte of Person or Firm• ...V FR a'FM .. .C..a'LE t 1. L- c --
Street Address/PO Box- le C°570 6.L41.7..-f ,,TY.. T-s L friN
CityiState"%p Cnde: > i .sF fgAY —.FA L F AIL 2 7/a(o
Office Phone: Mobile Phone. (334) 3f1-2'r171Fax Fax it.
If the financially responsible patty 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 EL-
If the financially responsible party is a partnership,provide information for each General Partner:
fuse blank page to Sist additional pastness i i 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.) 1 agree to provide
corrected information should there be any change in the information provided herein.
Type or Print Name: KI 4 ' d/G'Ta A t'6Re/if
Title or Autho PIC!7 $ER/OR44A/i?.E6 -- / �+
Signature. .. 4 Date: /�� / 2-�
/�
X r^
!111 MK.A`t{�...... i°k!S.IT€�YR a Notary Public of the County of.......1'r`=^'+ f
State of..14??:1t!L..Lf^r-a- ,do hereby certify that.. .._.t/.1eL l!1 1 ,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 ..311 day of C ^-J _..,20 7-.3...
\\`\a\a\a t u u w r n i,,,,,��
C1 `����co,TA S44,
Notary Public Name: 1I P.1 1(A + `N-A =P NOTARY 0y
- My Commission Expires
Notary Public Signature: r�-- 1___.-_-�J�x• -••• .1.1 July 17,2026
My commission expires: .....a1: ....1.1.t ' "a -AOl PUBLIC �`ar} Seal
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