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Home My WebLink AboutNCC216155_FRO Submitted_20211105City of Winston-Salem Field Operations Department I Erosion Control Division Oilice: I U()E, First Sheet, Stole 328, Wi33sion-Salem, NC' 27101 11111tiIIIIh501P111 \I,,iling: PO Box 2511, Winston-Salem, NC' 27102 Financial Responsibility/Ownership Form No person may initi;ue any land -disturbing activity exceeding 20,000 square feet for Single -Family Dwelling construction, 10,000 square feet for any other non-exempt purpose, or part of a larger common plan of development exceeding these thresholds, before this form and ,in acceptable Erosion Control flan have been submitted, reviewed, and approved by the City of Winston-Salem Erosion Control Division and it Grading/Erosion Control Permit has been issued. Please type or print. Please place "N/A" in the blank space if not applicable. Part A ProjectName:..�,1.yQ n......!................................................................................................................................................ -,Grading/Erosion Control Permit #; Location of Land -disturbing Activity: iLatitude: ................................................................................. Longitude: .............. .............................................................................. Approximate Date that Land -disturbing Activity will Commence: ......��1.�1. Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision esidential Single-family Lot/Lots ❑ Other Total Site Acreage - Acreage to be Disturbed: ................................................................. Grading/Erosion Control Permit Fee: S......".......................... Person to contact should Erosion Control related issues arise during land -disturbing activities: ,r, ray ,...�� . .f Uz3�yyoo:ComName:........................ :.. n.................... � Office Phone: ................................................... Mobile Pltane:.................. 911......... Fax #:................................................. Landowner of Record:: (use blank page to list additional owners ij'needed) Parcel PIN .{.45"'��1?.................................... Tax Block #:..... Tax Lot #:C.�...+�..... i2ona..L�'...a:,.�Sta�..!-....f....................................... Name: �i...IfS W . Street Address/PO Box:..�7- �7. .................CJ�........................................................... CitylState/Zip Code:......?�?.�a...V��+��JJ.....f!,................Za.SU...,................................... .,........... .......... ........................... .. . Office Phone: ..... Mobile Phonc�.`�...'�f�.�....�....(....� Fax #: .............................................. ...................................................... Grading Contractor Information: (if known at time ofs•ubrnitting the Erosion Control Plan for• review) altkhOWkk Value of Grading Contract: S................................................... City of WS Contractor ID #:,................................................................. Nameof Grading Contractor: ........................................................... I ................. NC License#:................................................................ Contractor Contact Person: .................................................................................. Contact Phone:............................................................... StreetAddress/PO Box..................................................................................................................................................... ................................. City/State/Zip Code: ............................................................................... ...................................................................................................... ...... Part B Person(s) or firms who are fitianejttlly respottsjbje for this land -disturbing activity: (use blank page to list ad"itionall* herson(s) or firms if needed) * **C'ontractors are nn7ot considered financially responsible for property not under tltcir awncrship Name of Person or 1�irm:.... kon.a.f t?(.,.....&P..Q.tii ....................................................................................... ...... ..... ....... Street Atidress1P013ox: ,..7.'T.i1.11,.. ,.f✓i�....,.Roa�i............................... ....................................................... ....... CitylStatclZip cods:.` b.R,cru,lhi.{.1.P.., ....., ,C.......................a.....................................,............I................... OA"cc Phone: ................................................... Mobile Phone: .`.. .-..�..�...T....J... Fax 0:........................................... ...... If the financially responsible party is an out-ol-state firm, provide information for the in -state registered agent: Name of Registered Agent: ........................................... Street Address/PO Box: City/State/Zip Code: ......................... Office Phone: ................................. Mobile Phone: .... Fax #: If the financially responsible party is a partnership, provide information for each Ceneral Partner: (use blank page to list additional partners if needed) Nameof Registered Agent: ....................................................................................................................................................................... Street Address/PO Box: ................................... City/State/Zip Code: ..................................................................................... OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:................................................. The above information is true and correct to the best of my knowledge and belief and was provided by me under oath. (This form trust be signed by the financially responsible person, if an individual, or their 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. Typeor Print Name: ...kloY.wd... A ....... L1.r. .�.1!�............................................................................................. Title or Authority:..!. tt<[..!-?n.!........a ........................................................................................................... e� Signature: ... �r••' .......��............ .......... ........ Date:.../� 1, ........... !GYr..11.......... °.!..f .�..^..".............................................. . a Notary Public of the County of ................ n ��. rsy....................... State of ....... Nor�q.... f ., l ; �� do hereby certify that ................ t .......A..................r..�.................. ,appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my hand and notarial seal this 0 c.4d b4 r day of................................................................... . 10 ........ ^ \� '`p tft 0 w'��i Notary Public Name; 0 ........................................................ [`P ti� a 'NpTAgk'•. Notary Public Signature: ....... ............. �.� My conunission expires: �� and y....... p 1c 11- //i,/RSYTHt,1N \xx� a