NCC242627_FRO Submitted_20240827

wiri City of Winston-Salem Field Operations Department Erosion Control Division
Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101
Wlnstoll•Salrlll 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
Havenbrooke-Phase 1 B
Project Name:
EN2400204
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: Havenbrooke-Phase 1 B-Lots 12 through 23,Lots 34,35 and 36
Latitude: 36.177 Longitude: -80.0450
Approximate Date that Land-disturbing Activity will Commence: 09/04/2024
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 4.64 Acreage to be Disturbed: 2.55
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Brant Dennis Email: [e-mail]
Office Phone: [phone] Mobile Phone: [phone] Fax#: NONE
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• See attached list Tax Block#: Tax Lot#:
Name: Garman Homes
Street Address/PO Box: 4000 Paramount Parkway,Ste 250
City/State/Zip Code: Morrisville,NC 27560
Office Phone: [phone] Mobile Phone: [phone] Fax#:
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: $ $10,00o ApproX City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/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: Garman Homes
Street Address/PO Box: ..4OAR P.aramnuntEkwy,Sie 250
City/State/Zip Code: Morrisville, NC 27560
Office Phone: [phone] Mobile Phone: [phone] Fax#: NONE
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.
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:....J VA
Street Address/PO Box:
City/State/Zip Code:
Office Phone: Mobile Phone: Fax it:
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 Namef.yaf-77
map'"�Title or Authority .. knAct c nm..11C
Signature: Date: s...
I, s'cncL r :s ` ,a Notary Public of the County of %t
State of North Carolina , do hereby certify that James H.Garman , 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 ( ,20 24
JENNA E SPAIN
nr\
Notary Public Name: ..r:... 1 Notary Public-North Carolina M
Notary Durham County
Public Signature: 0 My Commission Expires Sep 27, 2025
My commission expires: a' Notary Seal

PARCEL NUMBER LOT NUMBER Street Address
6898.14.4759.000 12 9187 Stoney River Lane
6898.14.4896.000 13 9181 Stoney River Lane
6898.14.5923.000 14 9175 Stoney River Lane
6898.15.5031.000 15 9169 Stoney River Lane
6898.15.5049.000 16 9163 Stoney River Lane
6898.15.5146.000 17 9157 Stoney River Lane
6898.15.5233.000 18 9151 Stoney River Lane
6898.15.5229.000 19 9145 Stoney River Lane
6898.15.5316.000 20 9139 Stoney River Lane
6898.15.5403.000 21 9133 Stoney River Lane
6898.15.5500.000 22 9127 Stoney River Lane
6898.154596.000 23 9121 Stoney River Lane
6898.15.3500.000 34 9126 Stoney River Lane
6898.15.3431.000 35 9132 Stoney River Lane
6898.15.3039.000 36 9168 Stoney River Lane