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HomeMy WebLinkAboutNCC241115_FRO Submitted_20240417 will City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101 VNUStnliSlllrl1 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: Pine Hall Erosion Control Grading/Erosion Control Permit#: EN2400065 Location of Land-disturbing Activity: 6702 Pine Hall Road, Kernersville Latitude: 36.23283 Longitude: -80.11154 Approximate Date that Land-disturbing Activity will Commence: March, 2024 Purpose of Grading: ❑ Commercial 0 Residential Multi-family ❑ Residential Single-family Subdivision ►l Residential Single-family Lot/Lots ❑Other Total Site Acreage: 6.28 Acreage to be Disturbed: 2.22 Grading/Erosion Control Permit Fee: $ 1,046 Person to contact should Erosion Control related issues arise during land-disturbing activities: Name: John Osborne Email: Office Phone: N/A Mobile Phone: N/A Fax It: N/A Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN#• 6970-25-1476.000 Tax Block#: N/A Tax Lot#: N/A Name: Jennifer Osborne Street Address/PO Box: 4982 West Road City/State/Zip Code: Kernersville,NC 27284 Office Phone: 980-229-7718 Mobile Phone: N/A Fax#: N/A Grading Contractor Information: (i f known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $ 15,000 City of WS Contractor ID#: N/A Name of Grading Contractor: N/A NC License#: N/A Contractor Contact Person: N/A Contact Phone: N/A Street Address/PO Box: N/A City/State/Zip Code: N/A 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: John Osborne Street Address/PO Box: 4982 West Road City/State/Zip Code: Kernersville Office Phone: 980-229-7718 Mobile Phone: N/A Fax#: N/A If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent: Name of Registered Agent. N/A Street Address/PO Box• N/A City/State/Zip Code: N/A Office Phone: N/A Mobile Phone: N/A Fax#: N/A 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: N/A Street Address/PO Box: N/A City/State/Zip Code: N/A Office Phone: N/A Mobile Phone: N/A Fax#. N/A 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. Type or Print Name: 1.10.447/441 a‘raig Title or Authority: i-6“voU �r Signature: '- —�' Date: ailagiq 1 rr,� ]1 1, I- a�-�a 6 n e, R, tiol-NA--e c.p I( ,a Notary Public of the County of Gut Tu�d State of N 'k Ca 1.61 nog, do hereby certify that s313ra'14"4: "'v 0 toorne- , 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 day of . utQ r1 ,20. Notary Public Name: 441---Prw 6ri-e• -R, 6`6'ce 1) KATHERINE R. WHITESELL NOTARY PUBLIC Notary Public Signature: .. ....., .. GUILFORD COUNTY, NORTH CAROLINA My Commission Expires itaxi50)2,0zto My commission expires. a`GaSo Notary Seal Landowner To Financially Responsible Party Permission Letter the Landowner of 6702 Pine Hall Rd (Print Name) (Sign Name)on 3...1...?:- (Dat9,) give the Financially Responsible Party, .. .. , (Print Name) (Sign Name) permission to acquire permits and complete the planned work on the property._ duetha Pule-1.0,5 ,a Notary Public of the County of State of../ti or .... do hereby certify that appeared personally before me this day,and being duly sworn acknowledged that the above form was executed by himther. Witness my hand and notarial seal. this 671-141 P9afth Nkltary Public Name 4e ceptlar Te,xlavio Notary Public Signature: 1, ,a1jA&L, 1?/oeksto My Commission Expires: 11/a8 1pZ , HEATHER PERKINS Notary Public- North Carolina xr,,,,,,,FoRM County MrytWfRistiTxpires May 17,2028 /'