NCC241115_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: [phone] 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: [phone] 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
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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 /'