NCC242169_FRO Submitted_20240718

i City of Winston-Salem Field Operations Department f Erosion Control Division
Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101
Winsltii illeni 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: Peters Creek Townhomes
Grading/Erosion Control Permit#: EN2300170
Location of Land-disturbing Activity: 3425 Peters Creek Parkway
Latitude: 36.026419 Longitude: -80.260296
Approximate Date that Land-disturbing Activity will Commence: July 22, 2024
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family E Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 18.48 Acreage to be Disturbed: 16.5
Grading/Erosion Control Permit Fee: $ 3,874
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Charles Hassinger Email: [e-mail]
Office Phone: Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#' 6823-80-2904.000 Tax Block#: 3867 Tax Lot#: 002
Name: Peters Creek Townhomes, LLC
Street Address/PO Box: 8480 Honeycutt Road, Suite 200
City/State/Zip Code: Raleigh, NC 27615
Office Phone: Mobile Phone: [phone] Fax#:
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: $ 1,502,627 City of WS Contractor ID#:
Name of Grading Contractor: Stewart's Grading and Hauling, InCNC License#: 68981
Contractor Contact Person: Adam Stewart Contact Phone: [phone]
Street Address/PO Box: 3420 NC-8 & 65-HWY
City/State/Zip Code: Germanton, NC 27019

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: Peters Creek Townhomes, LLC
Street Address/PO Box: 8480 Honeycutt Road, Suite 200
City/State/Zip Code: Raleigh, NC 27615
Office Phone: 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 Agent.
Street Address/PO Box.
City/State/Zip Code:
Office Phone: Mobile Phone: Fax#:
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:
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: Kenyon Burnham
Title or Authority: Manager
Signature,
Date: a7/ /(1 Z `�
icriA„-r , a Notary Public of the County of ivi 3n roe-
State of N" 7 9'1 16- , do hereby certify that 1 n'(-t u'�``��� , 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 7 44 day of , 20 )1
t�l�, v :t.�cp:ar
Notary Public Name: .. �1�-,� No7i;i','r r��t..r,'.t; S��o-1i't�ty-PJ�VdYORK
r RFn,i:(3tfl lir:n No.o1VO6193134
' �^ '� Qualified in Monroe Cowl
Notary Public Signature: L�^�"'� 1(°�(�'"`` �— M Co,T,mi.3ion Ex Tres 9/8/20
My commission expires: 1 —5-Z(>!
Notary Seal