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Home My WebLink AboutNCC216229_FRO Submitted_20211109City of Winston-Salem Field Operations Department f Erosion Control Division Oft -ice: 14d E. First Street, Suite 328, Winston-Salem, NC 271Q1 1Ulii5IN-31ahYq 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 nori-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 [�linston-Salern Erosion Control Division and a Grading/Erosion Control Permit has been issued. Ptease type or print. Please place `NIA" in the blank space if not applicable. Part A Project Name:.... ?"..z.�..... Irk Grading/Erosion Control Permit # :.............._.................... Location of Land -disturbing Activity: .................,1 ......v Latitude : ..................•.... Longitude:........................................................... Approximate bate that Land -disturbing Activity will Commence: .... ........................................ / Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision Residential Single-family Lot/Lots ❑ Oth(,r Total Site Acreage: ...... 4.4............................ I.......... Acre g be Disturbed: z................................................... a e to .. Grading/Erosion Control Permit Fee: S ..................... ..... Person to contact should Erosion. Control related issues arise during land -disturbing activities: Name:..../I.l..'.?"'/ ?IXt.'. y......................................... Email:..7�� eC�. �o�....... ... Office P)ione:................................................... Mobile Phone:Pax # Landowner of Record: (use blankpage to list additional owners f'needed) Parcel PIN #:..5~ 7 -- 4 ........................... Tax #:. f�A7 ..... .. .... Block ........ Tax Lot #:...�----�........... Name:.... �fl l!--. , fc ............ : &.S..................................................................................................................................... Street Address/PO Box:... �T ... a , ✓ --- zS.... xeI' City/State/Zip Code: ....... 2............................................................................................ Office Phone: ................................................... Mobile Phone:...`%/`�— 32 Fax #: Grading Contractor I nforrn ation: (if nown at time of submitting the Erosion Control Plan for review) Value of Grading Contract: :. '`'........................... City of WS Contractor ID 9:......... &.g.................................................. Name of Cxrading Contractor: A.60.FF.... 4A,!� %?S......................... NC License #:...... !.`F.................................................. Contractor Contact Person:.... 7; pe .... t q ............... ............. Contact Phone: 33G ---T" —�/` ....................................... ..�......... . StreetAddress/PO Box . ..... Q'0 .... LTb I .!.......................................................................................................................... City/State/Zip Code:.... Z (WJS 11Z L�� /t/.L' 2 702 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: ..�.1. fzer-y. ��lz4y ?'-r... ? :.......................... Street Address/PO Box: _.%I �.. d •�NGJ...ITC'.� � City/State/Zip Code: !� �`'/lt��fL+ .ez!? Office Phone: .... Mobile Phone: 3G— y g- 32 Pax ft:........... If the financially responsible party is an out-of-state firm., provide information for the in -state registered agent: Name of Registered Agent-,. ........ ............................ StreetAddress/P0 Box: ................................................ City/State/Zip Code: .................................................................................................................. ........................................ OfficePhone: ................................................... Mobile Phone: ................................................ Fax #: ....................... ........................... If the financially responsible party is a partnership, provide information for each General Partner: We blank page to list additional partners if needed) Nameof Registered Agent: ........................................... ...... ............................................................................................................................. Street Address/PD 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 fonn must be signed by the financially responsible person, if an individuat, 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 he any change in the information provided herein. Typo or Print Name. ....TM... ................................... ....... Title or Authority: .. 13! s. ep. g?�r - Signa .... ... ... .......... �............................................................... Date...... f S 2 a Notary Public of the County of .......... 1, .. 3! C ................... ......... .......��........ ............../ y y . . appeared State o£ ............................. . do hereby certify that ............................... .. ..... ............. .... , personally before me this day, and being duly sworn, acknowledged that the above form ways executed by him/her. Witness my hand and notarial seal, this ....................... G .... day ofC: , 20 .._ 1�� PuBL1�'IXI/z��frr.. ............. .. • Notary Public Name: ....�� .r Notary Public SignatureOY My commission expires: ...!...I.... otar„v�� III�f�f '�N lf3ii433 ��