The URL can be used to link to this page

Home My WebLink AboutNCC215679_FRO Submitted_20211013STORMWATERIEROSION CONTROL DIVISION 100 East First Street, Suite 328, Winston-Salem, NC 27101 R Financial Responsibility/Ownership Form d 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. 1f a question is not applicable, please place "NIA" in the blank space. PART A Project Name: Skylark Acres Sec II Subdivision Permit #j2_1 ---------------------------------------------------------------- ----------------------_-----_-_----____---_----- Location of Land -Disturbing Activity: 5707 Skylark Road-, PIN # 5897-18-3870.000 --- --------------------------------------------------------------------------------------- Latitude 36.1558 Longitude -80.3841___ Approximate Date to Commence Land -Disturbing Activity: As soon as permitted PP g Y� ----- ------------------------------------------------------------------ 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: --_- 8.75+1___ __ - Acreage be-Disturbed:_-_-8T80+1_______ Perm Fee: . 2 2 = __ ____ _.___-__-_.�.._______ ______________ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name __ Robert Weidl _______-_ E-mailaddress ------------------------------------------- 75 Telephone -------------------------------- Cell # _-- 336.577------------- Fax # --------_----------------------- landowner of Record (use blank page to list additional owners): Weida Properties, LLC 336.577.7775 ------------------------------------------------------:._-______ Name ®wners phone # Name Owners phone # 2806 Reynolda Rd, #172 _______________________________________________________________ Street Address/P.O. Box Winston Salem, NC 27106 --------------------------------------------------------------- City/State/Zip Code Tax Block #: _ 4633------------ Tax Lot #: ----- 111C-------. Street Address/P.O.-Box------------------------------- --------------------------------------------------------------- City/State/Zip Code Zoning: - RS30------____ Zoning Approval:-.PBR2021_002_ Contractor Information Required friar to Permit Issuance North Carolina State Lase 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 C10) s Revenue Offlee. s A Z-0 Value of Grading Contract City of W-S Contractor's ID # (d S (- Name of Primary Applicant (Grading ontract r) Contra's N. C. License umber Street Address/P.O. Box Contact Person for Contractor -710 7 S7-7- -2-7 Z City/State/Zip Code 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. Weidl Properties, LLC Name Wf Person-or-Pirm-----------»------------------------ 2806 Reynolda Road, #172 Street Address/P.O, ----------------- -,,--------__- Winston Salem, NC 27106 cayistarizip -`"-----------------»_-__.__------- caa._.___ 336.577.7775 Daytime Telephone #-----------. -----------------------------»---_---------._-_-_____.____--__- Name of Person or Firm ----s-Box ---- »» -------------------------------- -----------_---- Street --_ -----ip Cade - ----- ----------------`-_.__-------------------- City/ ------------� Daytime Telephone # 2. If the financially responsible party is an out-of-state resident, givethe name and street address of the registered in -state agent. Name of the Registered -Agent ----------»--»---------------- Street Address/FO.-Box------------------------------------- ---------- City/State/Zip Code - ------------------------------ ----------- ------- --- »------------"-------------- Daytime Telephone # 3._itlb?-XmmciaUy tcspwWhte.p=y is a partnership, give the name andaddCeS sLf-each..QORe7W..1"A=or4Se blank page to list additional partners). Nddress--- BoxStreet Address/P - ame of the General Fartner------------------------------- Name of the General Partner -------__--------------------- A--------------------------------------- -- Box------------------___------------__-- Street City/State/Zip Code ----------------------------- ------------ City/State/Zip Code `-_---"-_--------- __ ______ ._----___--- Daytime Telephone #----- --_��- DaytimeTelephone# The above information is true and correct to the best of niy 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. Robert Weidl for Weidl Properties. LLC Member -Manager Type N-f-- -ri fZ__-____»...-_. Title-or��th�1�_-__--T�-----------_-_�--------------.,......... Signature- Date ................... Ve� --------- , a Notary Public of the County of .... IF-Q�( _ �Ct[_l----------- - --- State of North Carolina, do hereby certify that ..... Raot__�� ---- W ea— -------_------------ 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 y of — ----------------------- My commission expires: Q(4 I w1up Notary Public NICKIE PARKER NOTARY PUBLIC FORSYTH COUNTY STATE OF NORTH CAROLINA MY COMMISSION EXPIRES O4-12-2026