NCC240260_FRO Submitted_20240129

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City of Winston-Salem Field Operations Department Erosion Control Division
011icc IOU L. First Street,Suite 328,Winston-Salem,NC 27101
I14itc ioSalelll Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial Responsibility/Ownership Form
No person may initial any land-disturbing activity exceeding 20.000 square feet for Single-Family Dwelling construction, 10,000
square feet fur any otl er non-exempt purpose,or part of a larger common plan of development exceeding these thresholds,before this
form and an acceptab Erosion Control Plan have been submitted,reviewed,and approved by the City of Winston-Salem Erosion
Control Division and GradingErosion Control Permit has been issued. Please type or print.Please place"NIA-in the blank space if
not applicable.
Part A
Peppertree Lots 7-10, 68-73
Project Name:
Grading,Erosion Cot4rol Permit#:
Location of Land-disturbing Activity: Orchard Path Drive. Clemmons .. µ
Latitude: 36.002 Longitude: -80.3620 .. ..
Approximate Date th t Land-disturbing Activity will Commence: Oct/Nov 2023 ..
Purpose of Grading:
❑ Co mercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
Resi ential Single-family Lot/Lots ❑ Other
Total Site Acreage: .1 Acreage to be Disturbed: 2•5
Grading/Erosion Con of Permit Fee: S
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Austin McGuire Email: _austin.mc9uire3@.9mail.com
Office Phone: Mobile Phone: Fax 4:
Landowner of Record: (use blank page to list additional owners f needed)
Parcel PIN#• Portio4 of 5892-72-2564, 5892-62-8496 Tax Block#. Tax Lot#•
Name: Hubb rd Realty of WS Inc
Street Address/PO s • 1598 Westbrook Plaza Drive
City/State/Zip Code:. Winston-Salem, NC 27103
Office Phone: Mobile Phone: Fax#.
Grading Contractor Information: (if known at time of.submitting the Erosion Control Plan,for review)
Value of Grading Contract: S City of WS Contractor ID 4:
Name of Grading Contractor: ... NC License#:
Contractor Contact Person: .. ... . Contact Phone:
Street Address/PO Bo C: ........
City/State:Zip Code: .

Part B
Persons)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**•
Name of Person or F rm: McGuire Construction Co., Inc.
Street Address/PO B x:13
4007A Country Club Rd
City/State/Zip Code: Winston-Salem, NC 27104
Office Phone: t Mobile Phone: [phone]
..........— Fax#:.... ...........
If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered ►gent•
I
Street Address/PO Btx•
City/State'Zip Code:
Office Phone: Mobile Phone:...... Fax#:
lithe financially responsihle party is a partnership,provide information for each General Partner:
(use blank page to list additional partners if needed)
Name of Registered gent:
Street Address/PO B x:
City/State2ip Code:
Office Phone: Mobile Phone: Fax#:
The above informatiot is true and con-cet to the best of my knowledge and belief and was provided by me under oath. (This form
must be signed by the ancially 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 ould there be any change in the information provided herein.
Type or Print Name: ustin McGuire
Title or Authority sident
00
Signature: .. if
y - hate: .. .� �
1• LQr-13 •C'rH•F� , a Notary Public oftheCountyof...ECL5 .t .
^ � 1 [� /� I Q l M � .,•,
State of.No.r...11..S..aL.Q,i//1 do hereby certify that...,1�,. .5.11,tQ ` Zt z/L�,,, .
appeared
personally before me is day,and being duly sworn,acknowledged that the above form was executed by hire%her. Witness my
hand and notarial seal this. /51 day of ..December ,20 23.
•
Notary Public Name: Lore Cry .%Y ; LORA J. GRAFT �.
:t•ire
NOTARY PUBLIC
Notary Public Signatu e: _. .... --
�`��� FORSYTH NC
Q .. sr. t o 4/� 7
My commission expires: .f 1 /../...R.�D.t &QC 7 - Notary Seal T