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Home My WebLink AboutNCC204646_NOT Supporting Documents_20210411STORMWATERIEROSION CONTROL DIVISION b� 100 East First Street, Suite 328, Winston-Salem, NC 27101 Financial Res ponsibilitylOwnership Form r 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 L� Skylark Acres Permit # 1_ l_ Project Name: --------..___________________»__. _.------------------------».».--------------------E62000---------------------__. __ Location of Land -Disturbing Activity: __- 0 Skylark Road; PIN ## 5897-18.3243---------------------------------------»---------- Latitude 36.1558 Longitude Approximate Date to Commence Land -Disturbing Activity: As soon as permitted pP g ty'------------------------------------------------------------------------- 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: »----- 4.626+/..- -,--� Acreage to be Disturbed:-__---2.27+1w-___ Permit Fee: ------- ------------------ ------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Jeff Guernier _____________ E-mailaddress jguernier@truehomesusa.com ----------------------------------------------------------------------------- Cell # 336.451.6682 Fax # Telephone------------------------------------------------»»----------- ------------------------ Landowner of Record (use blank page to list additional owners): True Homes, LLC (704) 507-0295 _ Name ------------------------------------- Owners phone# - Name ____ . _.-------------------___-__ 2649 Brekonridge Centre Drive Street Address/FO. Box ------------------------------------ Monroe, NC 28110 CitylState/Zlp Cade Tax Block #: 4633-_---_----- Tax Lot #: 111 D -- ------------- Owners phone # --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code Zoning:. RS20-»-------- Zoning Approval: --------- --------- -__- Contractor 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 Ilse 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 LLC Name ofPersan�or-Finn------------------------------------- 2649 Brekonridge Centre Drive Street Address/P.O. Box------------------------------------ (704) 507-0295 ........... -------------------------- Daytime Telephone # -- ------------------------------- Name Person orFirm -------------------------------------- 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. Name of ------------------------------ ----t Zip Cade ------------------------------------------ the Registered AgentCity Street Address/P.O. Box ----------------- Daytime Telephone #._.------- 3..-Lttbo-Omciaily_respmdh),vLpArty is a partnership, give the name blank page to list additional partners). Name of the General Partner ------------------------------- Street Address/P.O. Box ------------------------------------ City/State/Zip Code ----------------------- ------- ------------- Daytime Telephone # --------------- 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.) I agree to provide corrected information should there be any change in the information provided herein. ________________________ Member -Manager --- ---- ------ Member -Manager _------__--_--------___-_----_--_- Type or Prin;N Title or Authority -------=-------- . ;:.. -------------------------------- 5ignatu Date ---�,C_DS!a Notary Public of the County of ................ ---------------------------------- State of North Carolina, do hereby certify that —4aC _______ _____________________ ___ _ appeared personally before me this day and being duly sworn acknowledged*%the� uted by him. 20q� Witness my hand and notarial seas, this J- _-_day of _- -- -- �•{!3 $� Natar�r - is -c'022___;-_---= a�---s-------------------------------. M commission expires: � � y p------_ -- -�� { GUC�_ -.__ o O �s'�'�i N i i i��`�