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Home My WebLink AboutNCC215351_FRO Submitted_20210928STORMWATER/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 fbet 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: Petree Ridge _ Lots 10 & 21-24 Permit # Location of Land -Disturbing Activity: T" Petree Road Latitude 36.132029 Longitude-80,333650 Approximate Date to Commence Land -Disturbing Activity: August 16, 2021 ------------------------------ Purpose of Grading: Commercial Residential Multi -family Other (No development proposed) Residential Single Family lot Residential Single Family Subdivision Total Site Acreage: _1.37----------------- Acreage to be Disturbed: Permit Fee: Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Todd Isenhour toddisenhour@isenhourhomes.com --------------------------------------------- E-mail address _ .---------------- -- ---------------------- Telephone 336-345-1214 -------------------------------- Cell #----------------------------- Fax # -------------------------------- Landowner of Record (use blank page to list additional owners): Hubbard Realty of Winston Salem, Inc. 336-723-0303 --------------------------------------------------------------- Name Owners phone # Name Owners phone # 1598 Westbrook Plaza Drive, Suite 200 --------------------------------------------------------- _ _- -----------------------------_--------------------------------- Street Address/P.O. Box Street Address/P.O. Box Winston Salem, NC 27103 - ------------------------------------------------------------•- -:----------:------------------------- City/State/Zip Code City/State/Zip Code 3471 411 B RS9 Tax Block #: _____________ Tax Lot#: _____________ Zoning: -____________. Zoning Approval: ................... PIN: 6806-69-4339 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 I . 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. Isenhour Homes, LLC Name of Person or Firm 3411 Healy Drive ---------------s_;1F6------------------------------------------ Street Address/P.O. Sox Winston Salem, NC 27103 --------------------------------------------------------------- City/State/Zip Gode 336-345-1214 --------------- --------------- ------. 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. -------------------------------------------------------------- --------------------------------------------------------------- Name of the Registered Agent City/State/Zip Code ------- ------------ --------------------------------------------------------------- 5#r-eet Address/P.O. 8ox Daytime Telephone # .£lhs_6atancia�Uy.Lesp�nsibJ�p�rty is a partnership, give the name blank page to list additional partners). ---------------------------------------------------- --------------------------------------------------------------- -Name------of the-Gen---eral Partner Name of the General Partner --------------------------------------------------------------- --------------------------------------------------------------- Street Address/P.O. Box Street Address/P.O. Box -------------------------------------------------------------- ------------------------------ Gity/State/Zip Code City/State/Zip Code -----____ ----------------------------------- -------------- --- Daytime Telephone # 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 ' an individual or his attorney -in -fact or if not an individual by an officer, director, partner or registered agent with authority to execut stru ents for the financially responsible person.) I agree to provide corrected information should there be change in the info ation pr vided herein. Manager IsPtu _ sLLC ----------------------- --:-----------------------------...---- --_-------------------- TTitle or Aut ority -- -------------------------- a� _ d�I------------------------------------------- Si Dad - _DW1, _-�- _ --------------- , a Notary Public of the County of g1........ (�C? (---------_------_-_____-----' State of North Carolina, do hereby certify that 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 __ aS #)da of -- ,, 20 �)_L . y - - ----- . U4------- -- ----- trrL-"?------------- r My commission expire , t !-- J �� r .��//'/CK IC C)\ 1 ��