The URL can be used to link to this page

Home My WebLink AboutNCC210718_ESC Approval Submitted_20210205STORMWATER/EROSION CONTROL DIVISION 100 East First Street, Suite 328, Winston-Salem, NC 27101 Financial Responsibility/Ownership Form Erosion Control Ordinance No person may initiate any land -disturbing activity exceeding 20,000 square feet for a single-family dwelling or 10,000 square feet for any other purpose, before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Erosion Control Section of the City of Winston-Salem/Forsyth County Inspections Division. Please type or print. If a question is not applicable, please place "N/A'' in the blank space. PART A / Project Name: Location of Land -Disturbing Activity: Latitude 36. j gl V Approximate Date to Commence Land -Disturbing Activity: Purpose of Grading: 9 Commercial 9 Other (No development proposed) 40 ac v- - - - - - - - - - - - - - - - - tmmmo Permit # Longitude — go • 34 SL.Z ----I=1-r! ae-4--------------------------------------------------- 9 Residential Single Family lot e Ja mg a am yy . ubdivision Total Site Acreage: _J Z P , #----S0`3o�Permit Fee:'� Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name -_S^_Sw 1`M--------- E-mail address -/tip 1te E! C+OV! 5�seefidab UtJ±ct'• C Telephone -------------------------------- Cell # 3 �_ �f0 r_�_-_/S,�.t------- Fax it -------------- Landowner of Record (use blank page to list additional owners): V cG--aae�-=------- -`r-Zr!!-9 5- _�Y 7s Kt. f C-:a—_ Name // Owners phone # Name-------Owners-phone # -J42O.? _?7F_fL�----------------- ---__Address/P.O. Box Address/P.O. Box Street Address/P.O. Box City/State/Zip Code - - --- City/State/Zip Code "--------------------------------------- Tax Block M --- - ----- -----. Tax Lot #: ..... a:3 --- Zoning: �5 ----� g' � ....... Zoning Approval: ................... Contractor Information Required Prior to Permit Issuance North Carolina State Law requires that contractors be licensed to perform work valued at $30,000 and higher. All contractors must have a City of Winston-Salem contractor's IM, available at no cost through the City's Revenue Office. Value of Gradin Contract iL ICi A.Gt Sea N e of Primary p licant (Grading Contractor) .6 .$6 S##r et Address/P.O. Box l r�crsrr64 ,,r/C 2728 — City/State/Zip Code ".27 City of W-S Contractor's ID # 7.2 342 Con ract is N. C. License Number ta�<< Contact Person for Contractor 33e.-z1dY /spa Contact Person's Daytime Phone Number PART B 1. Person(s) or firms who are financially responsible for this land -disturbing activity (use blank page to list additional persons or firms). Contractors are not considered financially responsible for property not under their ownership. --- -- -------------------- N�ne of Person or Firm lo0 7 Al 4,ev viceS 5T7Z�-T- --------------------------------------------------------------- Street Address/P.O. Box Sou, .3r-.vr�,T✓_ yGGI 7 _- y/Sta�_--- =----= ------------------------------------- -CitteMp Code Daytime Telephone # --------------------------------------------------------------- Name of Person or Firm --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code ........... -------------------------. Daytime Telephone # 2 If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. : t�_VErzrrrrs G¢o�A , Twc -_ �i�rrrsv�cc�- C 72 - ---------------------------------------------------------- --------------->-N------�5— e of the Registered Agent C' /Siate/Zi Code ------------------------ s 334 - Yo V -is-a- a, �h' p �.�-------------------------------- -------_---------------------- ----------------------------------------- Street Address/P.O. Box Daytime Telephone # 1aft5=CiAUY_rQSPPAdlJ.fLPA9y is a partnership, give the name andbiank page to list additional partners). ----•---------------------------------------------------------- Name ofthe General Partner Street Address/P.O. Box -- ------ ----------------------- --------------------------------------------------------------- City/State/Zip Code Wie-l-------------- ---------- Daytime Telephone # Name of the General Partner ------------------------------- --------------------------------------------------------------- Street Address/P.O. Box City/StatelZip Code ------------------------------------------ - - Daytime Telephone # 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 his attorney-' -fact or if not an individual by an officer, director, partner or registered agent with authority to execute instruments for the financially ible person.) I79rto provide corrected information sho erree any ch a in a information provided herein.Type or Title or Au hors ------------------------ Sinature--_-_._- - ----_6- - - ?-� ------ ---------- ------------ Date a Notary Public of the County of State of North Carolina, do herebycertify that i - __�'�:c�h�A,9__- r��o� -- =-fir ►tQ__GYo_� appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this ---5 ------day of iY_11 1C1Y Ul 20 ,qA� NpHtta My commission expires: _ CA _ , � 7 40TA#;**. VBL IC ,Z C)