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Home My WebLink AboutNCC216047_FRO Submitted_20211108City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 MIM11119 Mailing: PO Box 2511. Winston-Salem, NC 27102 Financial Responsibility/Ownership Form No person may initiate 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 an acceptable Erosion Control Plan have been submitted, reviewed, and approved by the City of Winston-Salem Erosion Control Division and a Grading/Erosion Control Permit has been issued. Please type or print. Please place "NIA,, in the blank space if not applicable. Part A Project Name:.CANVASBACK LAKE DAM REPAIRS .............................................................................................................................................................................. Grading/Erosion Control Permit#:.EN2100117......................................................................................................................................... Location of Land -disturbing Activity: 2l WALKER ROAD, WINSTON-SALEM, NC (PFAFFTOINN, NC) .................................................................................................................................... Latitude: 36.1$4482..................... ... Longitude:.:80: 326967............................................................................................................... Approximate Date that Land -disturbing Activity will Commence: NOVEMBER 1, 2021 ............................................................................................................ Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots Total Site Acreage: 26:34.............. Grading/Erosion Control Permit Fee: $ $1.,248 ................... ® Other Acreage to be Disturbed:. 3 . Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: ' N T.: GRIMES, PE ............... Email:JTGRIMES@GRiMES-ENGSNEERiNG.CO4� ............................................................................................................................................ 336.480.8500 336.480.8500 NIA 011icePhone: ................................................... Mobile Phone....................................................... Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) ParcelPIN#:.................................................................................. Tax Block #:.................................. Tax Lot #:................................... Name:.................................................................................................................................................................................................................... StreetAddress/PO Box: ...................................................................................................................................................................................... City/State/'Zip Code: ............................................................................................................................................................................................ OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:................................................. Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Valueof Grading Contract: $................................................... City of WS Contractor ID#:.................................................................. Nameof Grading Contractor: ............................................................................. NC License#:................................................................ ContractorContact Person: .................................................................................. Contact Phone:............................................................... StreetAddress/PO Box: ..................................................................................................................................................................................... City/State/Zip Code: ........................................................................................................................................................................................... Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional person(s) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm: MALLARD LAKES ASSOCIATION .................................................................................................................................. Street Address/PO Box: ...PO BOX 45 City/State/Zip Code:.BETHANIA NC 27030 A, ............_.. OfficePhone: ................................................... Mobile Phone....................................................... Fax #:................................................. If the financially responsible party is an out-of-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 General Partner: (use blank page to list additional partners if needed) Nameof Registered Agent: ................................................................................................................................................................................ StreetAddress/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 must 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. Type or Print Name. DENNIS FORD ...................................... Title orAuthori PRESIDENT - MLA ........................................................................................................................a............................... Signature:...........t. :...........................................,............................ Date:..... �..../... �1..°�... ?.. ........ I.....Ll. .. ..... ML W .!n.............................................. . a Notary Public of the County of 101 .......................... State of .... ujg�a......... , do hereby certify that ......... CS.&A�........ KNA............................. . appeared personally before me this day, and being duly sworn, acknowledged that the above form - wass executed by him/her, Witness my hand and notarial seal, this ......................... ��...................................... day of .......... �J.�:��.K. ................................... , 20 L7�.k..... OMNI A McCOI_LUM NoM Notary Public Name: ...Cm3 i� � �.. � l: �.4�Y.� :i............. warywaryF"Public - c Carolina Notary Public Signature: ... ...............:. .. My commission expires: ......... . �JJUMN.............................. Notary Seal