NCC242546_FRO Submitted_20240822

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City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 32S.Winston.-Salem,NC 27101
i4S 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 pan 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-NIA"in the blank space if
not applicable_
Part A
Project Name. .6?7/2 Co iduit fer / &i Y4 Crime
GradinaiErosion Control Permit#: ....ON A2-00� 19 Z'L.L.
Location of Land-disturbing Activity: 7 Q i L eastA k/J. w ' Y 5Y7eikec =, ,G 271- '7
Latitude: 31 ? 3 v 3 9'7 Longitude: WO, 03.9 2
di
Approximate Date that Land-disturbing Activity will Commence:
Purpose of Grading: .
0 Commercial ❑ Residential Multi-family 0 Residential.Single-family Subdivision
ti esidential Single-family Lot'Lots 0 Other
Total Site Acreage: I' 1 Acreage to be Disturbed: • 93
Grading%Erosion Control Permit Fee: $ /00'
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: ... . c........1.,.1.(.6.4.ven Email:
Office Phone:3 -$.5?"" Mobile Phone:.,33A.S'#3 Fax#: .414
Landowner of _
Record:r Ode blank page to list additional owners if needed)
Parcel PIN#:......i:e,0'!3 -3/, '0 ' Do0 Tax Block#: Tax Lot#:
Name: tS Cr(.e/,C.11keete.�(M r
Street Address/PO Box:..6 d 7 l`i 4-,`t41 .o 1 1Lt Of
C ityiStatclZip Code:....4 �l e+'`5 it ,�,.�r _K ....6 ' .• ?70 D
Office Phone: Q"S52'Js/s Mobile.Phone:.17,6-Cj r 3.-57.-r Fax: i%
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan Pr review)
Value of Grading Contract:S City of WS Contractor ID#:
Name of Grading Contractor NC License#:
Contractor Contact Person: Contact Phone:
Street AddressiPO Box:
.1/41/1/
City/StatelZip Code:

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: ell(f c e-,fierVerit
Street AddresslP{J Box: - 4P0 7 /#14 el 90 Pp,11k-Q f c ele.>-�k.�,... - C • ,2 7Do 9
City/State/Zip Coder/»
O#Iice Phone:
14.5.���3s7� Mobile Phone:.-fir -'.-'� 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 Bow Aj/A*
'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: r -
Office Phone: Mobile Phone: Fax#:
The above information is true and correct to the best of my know ledge 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 lino.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: Cri "$ e_( 41et
1‘1.--
Title or Authority: r ti°4►i'et7
. 0a,,,pvi--.---- g .'4-2 V
Signature: av i'" Date:
I, �> '00i.. A, . . l.1\, a Notary Public of the County of... 0. .
State of 111.0)L ..•�'11 .r ,do hereby certify that � i. ..... 'l ,appeared
personally before the this day,and being duly sworn.acknowledged that the above form was executed by himlher.Witness my
rr day of s. ,202.4..•
hand and notarial seal,this +14� "". �
ott+uaituifiri
Notary Public Name: . Y�� U2i l`.'.1..5 .1..L..\.,k ti .�.••CA c
Notary Public Signature: .. y t . ilka- •
My commission expires: 10.L i5.12c yz • /Seal
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