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Home My WebLink AboutNCC215907_FRO Submitted_20211025STORMWATER/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 Count,,, Inspections Division. Please type or print. If a question is not applicable, please place -N/A" in the blank space. PART A Project Name: _ BELL -WEST--PHASE ---------------------------------- -1 Permit -# ---------------------------------------------------------- Location of Land -Disturbing Activity: Latitude 3 6. 0 994280 Kernersville, NC ------------------------------------------------------------------------------------------------- Longitude 8 0 . 1481510 Approximate Date to Commence Land -Disturbing Activity: Purpose of Grading: 9 Commercial 9 Other (No development proposed) FALL 2021 ------------------------------------------------------------------------- 9 Residential Multi -family 9 Residential Single Family lot 9 Residential Single Family Subdivision 22.30 AC $ 5288 Total Site Acreage: 37 -. 3 -- -Acreage-to be Disturbed_ _ ________Pet Fee: _ __ Per--- ----------------------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name _Mike -- Adams madams@rsparkerhomescom ----------------------------------- E-mail address --------------------------------------.------- Telephone -� 3 3 6) 3 9 9 = 7 917--------- Cell # --( 8 4 3) 7 8 0 _ 112 8----- Fax # ________________________________ Landowner of Record (use blank page to list additional owners): BRAXTON REAL ESTATE & DEVELOPMENT-, LLC (336)399-7917 ------------------------------------------------------------------------------------------ ----------------------------------- Name Owners phone # Name Owners phone # 6420 Hampton Knoll Rd. --------------------------------------------------------------- --------------------------------------------------------------- Street Address/P.O. Box Street Address/P.O. Box Clemmons, NC 27012 --------------------------------------------------------------- --------------------------------------------------------------- City/State/Zip Code City/State/Zip Code Tax Block #: _ Tax Lot #:------------------ Zoning: - PRD RS _9 Zoning Approval: Contractor Information Required Prior to Permit Issuance :Forth Carolina State Law requires that contractors be licensed to perform work valued at S30,000 and higher. A11 contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. S Value of Grading Contract Name of Primary Applicant (Grading Contractor) Street Address/P.O. Box City/State/Zip Code Citv of W-S Contractor's ID # Contractor's N. C. License Number Contact Person for Contractor Contact Person's Daytime Phone Number lerson(s) or firms who are financially responsible for this land -disturbing activity (use blank page to list adcitional persons or firms). ,ontractors are not considered financially responsible for property not under their ownership. BRAX-ON REAL ESTATE & DEVELOPMENT, LLC --------------------------------------------------------------- Name of Person or Firm Hampton Knoll Rd. --------------------------------------------------------------- Street Address/P.O. Box =_emmons, NC 27012 --------------------------------------------------------------- City/State/Zip Code (336)399-7917 ------------------------------------ Daytime Telephone # ------------------------------------------------------------ Name of Person or Firm --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State'Z.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. --------------------------------------------------------------- --------------------------------------------------------------- Name of the Registered Agent City/State/Zip Code --------------------------------------------------------------- --------------------------------------------------------------- Street Address/P.O. Box Daytime Telephone # _jfibe_6nancially_r�sp9tLsiYzJ� parry is a partnership, give the name andaddLeu.OffaCh re,=A1_L`=wrjlLse bank 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. Greg Garrett -Man Member --------------------------------------------------------------- --------------------------------------------- Tn.or Print N 'i Title ?r Authority ------,�-ck ----------------------------- Date t-22---------------------- ----------------------- Signature � �1 �� i_ , a Notary Public of the County of _ o (l,_�� ti�---------------------------' r 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 _ J � -day of � �0 r-- -- ------- ^ -- ---7-,� -Y-`1-L--- C- - _- Z Z---------- ------- Notary Public My commission expires: ____ 7s 2(c_r Zf ZC _ �� t! ----------- NOTARY Ilk _p PUBLIC All CO.