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Home My WebLink AboutNCC230176_MODIFICATION Supporting Documents_20240709 (3) City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101 111IIS1111HSHIP111 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:...South Fork Village Phase 1 ............................................................................................................................................................................... Grading/Erosion Control Permit#: ............*94-*'. ....................... ......... . . ................................... 58 4-84-850�, 5894-84-4797, 5894-94-2408, 5894-74-7640 Location of Land-disturbing Activity: ..&.POft1.911.Pf.66.94-94-7979................................................................................................ Latitude: 36.06270 Longitude: -80.35900 ....................................................................................... ............................................................................................ 70 Approximate Date that Land-disturbing Activity will Commence: ............/1.../2024............................................................................................. Purpose of Grading: ❑ Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 25.10 ......................... Acreage to be Disturbed: 36.50 ............................. ................................................................... Grading/Erosion Control Permit Fee: $ .................................. Person to contact should Erosion Control related issues arise during land-disturbing activities: Name: .,..Kat Lyons.•..................................................... Email: .....kat;lyo9s leoterradevelopment.com ...... ...... ............................ Office Phone: n/a ............... Mobile Phone: 336-682-1414 Fax#:..n/a........................................ .................................... .............................I............ Landowner of Record: (arse blank page to list additional owners if needed) 5894-84-8509, 5894-84-4797, 5894-94-24081 5894-74-7640 & Portion of 5894-94-7979 ParcelPIN#:.................................................................................. Tax Block#: .................................. Tax Lot#:................................... Name: ...LeoTerra. ..Peace. . ..Haven. , .LLC....... ........... ........................................................................................................................................................................ Street Address/PO Box:...110 A Shields Park Drive .... ....................................................................................................................................................... City/State/Zip Code:....Kernersville,..North..Carolina... . ..27284. ............. ............ .......... .... ...................................................................................................................... Office Phone: 336-279-7280 Mobile Phone:............................ Fax#:.............................................. ... Grading Contractor Information: (if lcnoivn at time ofsubrnitting the Erosion Control Plan.for review) Value of Grading Contract: $ ................................................... City of WS Contractor ID#: .................................................................. Nameof Grading Contractor: ............................................................................. NC License#: ................................................................ Contractor Contact Person: ................................................................................. Contact Phone: ............................................................... StreetAddress/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 firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm: .LeoTer.ra..Peace. . ..Haven. . .,..LLC..... ... .... . .... .... . .... .... ................................................................................................. StreetAddress/PO Box: ..110-A Shields Park Drive City/state/zip Code: ..K 9ersville,.NC. ..27284. ..... ............. ......................................................................................... .. .. .. .... ...... . . Office Phone: .336-279:7280 Mobile Phone: _3.36-486:3653.. Fax#:................................................. ................... .... ................. If the financially responsible party is an out-of-state firm, provide information for the in-state registered agent: Nameof Registered Agent:............................................................ ..................................................................................... Street Address/PO Box:................................ ......................................... ......... City/State/Zip Code:... ............................. ........................................................... ............................................................. OfficePhone: ................................................... Mobile Phone: ...................................................... Fax#:................................................. If the financially responsible party is a partnership,provide information for each General Partner: (use blank page to list additional partners irneeded) Nameof Registered Agent:................................................................................................................................................................................ StreetAddress/PO Box:..................................................................................................................................................................................... City/State/Zip Code: ............................................................. ...................... ...................... .......................................... OfficePhone: ................................................... Mobile Phone: ...................................................... Fax#:................................................. The above information is true and correct to the best of my knowledge and belief and was provided by me wider 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 ean-y_change in the information provided herein. Typeor Print Name: .....Ck ............................................................................................................... Titleor Authority: ....... ................. .................................................................................................................... Signature: ........... .... .... .... ... ....................................................................................... Date: ....�.�.��................................ 1. ............D.O.Lstv...//............ ............................................................, a Notary Public of the County of.......... .......s0.+........................... State of....N ....l&�............. . do hereby certify that (Af`S1tli.fkA ......I............, appeared personally before me this day,and being duly sworn,acknowledged that the above form was executed by him/her.Witness my Q4+ �r hand and notarial seal,this .............................1............................................. day of ...............�,..! .....................................,2() ..Z . Notary Public Name: .. al�d^..CN` -....................... o ... .. .,y Notary Public Signature: ...... .................................................. NQTAf� � rolz•t� _-�: _ . _ :T My commission expires: ..............l.................................................. ON COv ''141011111"