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Home My WebLink AboutNCC203426_NOT Supporting Documents_20210411STORMWATER/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. Crescent Meadow Phase I ProjectName: ... ,.------------------------------ ----------------------- -- Permit #----- ____..__-_-__.____-_ --------_____-_____------ Location of Land -Disturbing Activity: -_- 5880 Styers Ferry Road; PIN # 5884-58-6597.00 ---------._ - --------- ___.» -_ _ -- ------. ---------------------------------- Latitude 36.0733 Longitude -80-4026 Approximate Date to Commence Land -Disturbing Activity: . As As soon as»permitted---^-----_»-_--»»__________________________ Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot 1X*Residential Single Family Subdivision Total Site Acreage: ___-__ 7 109+/________ Acreage to be Disturbed:-_»__-5.74*/--_-- 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---_------ Telephone Cell 336.451.6682 -------------------------------- # __._-_----------------------- Fax # __------------------------------ Landowner of Record (use blank page to list additional owners): True Homes, LLC (704) 507-0295 Name- --------------- ------------------- Ownersphone# 2649 Brekonridge Centre Drive --------------------------------------------------------------- Street Address/P.O. Box Monroe, NC 28110 __---______».-------------------------------------------------- CitylStatelZip Codc Name -.»-----------------------------------Owners phone # ----- Box ---------------------------------- Street Address --------------------------------------------------------------- City/State/Zip Code Tax Block #: 4427 Tax Lot #: 015D __ Zoning: _ RS30---------- 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 Is 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 LLC Name ofPerson-or Firm -----------------------------»------ 2649 Brekonridge Centre Drive street Aaarsm.0. Box------------------------------------ City/StatelZip Code (704) 507-0295 ------------------------------------- Daytime Telephone # Name -- -------------------------------------- Person or Firm ------ -O.Box --------------- ------------------------ Street Ad --------------------------------- ip 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. Namd Ae ofthe Registeregent------------------------------ City/State/Zip Code --------------------------------------- __ Street Address/P.O. Box - - ---------------------------------------- Daytime Telephone # 3 _If ibe-6nur.iaUy_Le,spwL,Ob ,pxV is a partnership, give the name and.,Aa,dCtialaoWh.GgD tpl,. wiuer�me blank page to list additional partners). Name of the General Partner ------------------------------- ------------------__...»---------------------------------------- Street Address/P.O. Bpx City/State/Zip Code ---------------------------- ------------- Daytime Telephone #------------ --M______ _______________________ Name of the General Partner --------------------------------------------------------------- Street Address/P.O. Box ------------------------------- --------------------- City/State/Zip 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 -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.)] agree to provide corrected information should there �e any change in the information provided herein. ------------------------------------------------ ------------------------ Type or Print Name Title or Authority ___ --�=---------------------------------------...____� Signatur# ; „r Date - --- ---------------- -------------- ' _-- .li. --__-L , a Notary Public of the County of _-_„ _.l = °:!___________________ ______ State of North Carolina, do hereby certify that iVL _G---------------------------- -- appeared personally before me this day and being duly sworn ackn( Witness my hand and notarial seal, this ___I_ ______day of My commission expires: -__-_. ►�111##r# �;as executed by him. 240ary Public" 0 _6 -------,. 10 "14'11" �Y& d �fi#il#1110►�`