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Home My WebLink AboutNCC215803_FRO Submitted_20211019STORMWATERIEROSION CONTROL DIVISION 100 East First Street, Suite 328, Winston-Salem, NC 27101 Financial Responsibility/Ownership Form Erasion Control Ordinance No person may initiate any land -disturbing activity exceeding 20,000 square feat 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-SalentilForsyth 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: ___�►CC/�D � w�,-_ � � NCS __ S �a o �v_ �S�o�..-_===��t�api �_a=_____________.___._---.._._..._.__-_--_--- Location of Land -Disturbing Activity: :°l \->8c__?5_`l_6!-A-- E3E i`y� _ V_ b � lei --------- Latitude NSoN -S hl sty c. � C 21 12-i 3_� a q 2� l O . S" tJ --- - Longitude c6o ° l7 ` _5 1. O " .- +' 9C2i Approximate Date to Commence Land -Disturbing Activity: _ __1_A� , >_2-6'2-_._...,-..-„__________________________ Purpose of grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposer!) 9 Residential Single Family lot `9 Residential 'ingle Family , ubtlavision Total Site Acreage:--Q�---�---------- Acn to beDsturbed60 �Permit Fee: _>___-._-__ __._. ----------------------- Person to contact should erasion and sediment control issues arise during land -disturbing activity: r Name ►Tc+1EU: _-�1 ��gN�f`Je --_--______C-mail address m ��;��:M�C�� Telephone __= 1� �q�1 �1 Cell 4 -------- -------------- Fax #------------------------v_.>---- Landowner of Record (use blank page to list additional owners): GL641l60a �16r&E$ LLC gtck_-ILAl—I'R 3 --a----e -------------------------------------O-- wn---e--rs - pho---ne ------- Nm ---------------------------------- -. Street Address/P.O. Box ------------------- C:itylStatelZip Code Tax Block #: Tax Lot 10 =------------------------------------- ----- -- Owners phone Name Street Address- .... Box ------------------------------------ iCylStatelZipodyy------_-_------------------------------ Z,oningo ... qZoning Approval: .................... Contractor Information Required Prior to Permit Issuance s�'nr7h Carolina State Law requires that contractors be licewsed to perform work valuer! at S30,000 and higher. All contractors must have a City of Winston-Salem contractor Is IDS, available at no cost through the City Is Revenue Office. $ L\5, o0o Value of Grading Contract -r _ V uyM\A a. "Ioc Name of Primary Applicant (Grading Contractor) ?o_ a X Ct C 4_-L-1 Street Address/P.O. Sox t� N LS-, tC-�t1 ILL 2-( 6�15 City/State/Zip Code City of W-S Contractor's ID # 3!\ i� 56 _- Contractor's N. C. License Number Contact Person for Contractor kC�- 11-0-0-1bq Contact Person's Daytime Phone Number P?#RT 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. Name of Person or E�irm Street Addressll?.Cl. Box City/StatefZip Code Daytime Telephone # ........................................ ----------------------- Name of Person or Firm ------------------------------------- ............. Street Address/P.O. Box ------ Code-------- ............................................ City/S ---_.__o____>. Da0me 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. City/State/Zip Cade Street AddressfP.Ci. Box __..>.,_.,............... ..>....... .... ......--_ ._...--- . Daytime Telephone # . Lt►� nciaUy tti5pt� p ly is a partnership, give the name and,d=arachfnnrAl.k'at=bL-se blank page to list additional partners). ................................_----_.--_.._--_.--__--_.-----_. Name of the General Partner ---- Box ------------------------------------ StreetAddress---------------------------------------------------------------- CitylStatalZip Coda ------------------------------------. Daytime Telephone # Name of the General -Partner--------------------.. ......... _. --- ------------------------------------- Street Address/P.O.Box tZip Code- _______________________________ City/State/Up 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. TN o mlvo_ ? v _ _!� .�4.� `. .................. '`� ------------------------- ----------- Type or_ n- 'ame . __ ............... Title or uthprity _._.____....___._=o__-=....... _ Si ure Date a Notary Public of the County of-----------------------------------___ State of North Carolina, do hereby certify that _., Q�5----__�»vi<-'_ u. —.---------------- ---- ----------- 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 da of ___ o_ _______ PZ12,%III lit_LYNlna--- -- -- - ------------------------ My commission expires: -_--_-_-- Z a --_�- _` Q •_,gyp T.4 ,,� C'OUN;I-4 ,