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Home My WebLink AboutNCC204222_NOT Supporting Documents_20210411STORMWATERIEROSION 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 "NIA" in the blank space. PART A _ Murray Place ----------------------------------------------Perrr�it #-- ___ Project Name: _.____------ Location of Land -Disturbing Activity: --_ 5305 Murray Road; PIN # 6818-49-1495 ---------------------------------------------------------------------------------------- Latitude 36.1868 Longitude Approximate Date to Commence Land -Disturbing Activity: _-_- As soon as permitted_____________________________________________ Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot XX*Residential Single )Family Subdivision Total. Site Acreage: ____-- 6_547+/__------ Acreage to be Disturbed:__-_--3.17+/----- Permit Fee: ----------- --- ------------------ ------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Jeff Guernier E-mail address _ Jguernier@truehomesusa.com Cell # ---- --- .----6682--------- Fax # _ Telephone-------------------------------- ---........____-------------------- Landowner of Record (use blank page to list additional owners): True Homes, LLC (704) 507-0295 Name ----------------------------------Owners phone #--- 2649 Brekonridge Centre Drive Street Address----- Box --------"------- ------------------- Monroe_ NC 28110- City/StatelZipCode ---------------------------------------- Tax Block #: 3491 Tax Lot #: 502A Name --------------------------------------Owners phone # ---------- Box ------------------------------------ Street Ad --------------------------------------------------------------- City/State/Zip Code __- Zoning: _ RS9__.------_- Zoning Approval: ------ N/A ----- 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 ID#, available at no cost through the City's Revenue Office. . ............ . Value of Grading Contract Name of Primary Applicant (Grading Contractor) Street Address/P.O. Box City/State/Zip Code City of W-S Contractor's ID # Contractor's N. C. License Number Contact Person for Contractor 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, True Homes L LC Name of Person or ltirm------------------------------------- Street Address/P.O. Box------------------------------------- Name -- Person or Firm------------------------------------- --- Box------------------------------------- Street AddresslP _ -----e-Code--- ........ City -""__--------------------------___--_ ____•____________________•_------- .._.................,...........»..__-_------- Daytime Telephone # 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. Name of the Registered -Agent- ----------------------------- City/State/Zip Code ------------------------------------------ Street AesslP. ddrO. Box------------------------------------- Daytime Telephone #----------------- --------- 3 _Vtbs_6=daUy_CespDndhJtpA1y is a partnership, give the name and. ad&a blank page to list additional partners). _----------------------------------------------------------- Name of the General Partner Street Address/P.O. Sox ------------------------------------ --------------------------------------------------------------- City/State/Z€p Code Daytime Telephone # Name of the General Partner ________________________ --------------------------------------------------------------- Street Address/P.O. Box ---- ------------------------------------------ City/State/ZipCode ............................ 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 -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 b y change in the information provided herein. ---- --'r- r�_�yl rr__.L ----------------------- Member -Manager ----------------- ............... _.. Type or Print Name Title or Authority :_' ?s` Signatures__. ---------------------------- Date ---------------------- 1 ------ --------------------- l al._A__QPe-: , a Notary Public of the County of --------- ----------------------------, State of North Carolina, do hereby certify thatJhX? ______ appeared personally before me this day and being duly sworn acknowledg Oft fie` 6ve fort/ t�Ucuted by him, a Witness my hand and notarial seal, this day of ___ n' r�2 - No blicsedl ®� - My commission expires; --_-_--, fil11111i111