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Home My WebLink AboutNCC216515_FRO Submitted_20211119P City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite' 28, Winston-Salem, NC 27101 1i�1151011$IIIIJII .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 "N/A" in the blank space if not applicable. Part A `" 1 1 Project Name:..... cc . ....... i .. .. ....1..'...`-..lJ� �.......................................................... Grading/Erosion Control Permit #:...............,�V.�.�1....................................... ........... .. ......... Location of Land -disturbing Activity: c i.. ..... �. ,. a, Latitude:.�s.��.�z.r:................................................ Longitude:.;.. ............................................... Approximate Date that Land -disturbing Activity will Commence:...#�..,1...�.. .r�`.............................................................. Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision k,R.esidential Single-family Lot/Lots ❑ Other Total Site Acreage:......1 .:.. .. .......................... Acreage to be Disturbed; .....1..-.J)A "-I,% Grading/Erosion Control Permit Fee: $ ... 1 ................ Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: Email:.. 7...opzzwoa, t`7.�'�..) YK Office Phone:..... .............................................. Mobile Phone:...1..4.:.:..1;.. Fax #:................................................. Landowner of Record: (arse blankpage to list a�d^diieio al owners if needed) Parcel PIN #:.i . R 5�...... C+ U� . ..]G! *Tax Tax Block # :.................................. Tax Lot #:................................... Name: �c ! .......�Az w&..!s..... .... ...................................................... Street Address/PO Box:.\'"! L�... ` 4 I �....... � .1... ............................................... City/State/Zip Code.......��.L�1141...4�.a}. �� ................l.l...................................................... Office.Phone:.1..8 Mobile Phone: ...................................................... Fax #:................................................. Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $................................................... City ar WS Contractor ID#:.................................................................. Nameof Grading Contractor: ............................................................................. NC License#:................................................................ Contractor Contact 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*** Nameof Person or Firm:....... �- .......................... Street Address/PO Box: LA50...... da".4... .,.. 6"-��... 1.1........ City/State/Zip Code `..... •. h l �`.� �.. ....... .......................... OfficePhone: . :.' ..5...4. ... Mobile Phone: .......................)............................. Fax #: If the financially responsible party is an out-of-state firm, pro, Name of Registered Agent �.`.��....... � .` Street Address/PO Boxe. .`;�<.....lk. . ........ City/State/Zip Code: ..4 ��.1 ........... Office Phone: ................................................... Mobile Phone. y:, ide information for the in -state registered agent: .................. ..................................... .................... �Q'L ... U ............................... ....1......,............. :... n .. .. �................................ Fax# :................................................. If the financially responsible party is a partnership, provide information for each General Partner: (use blank page to list additional partners if needed) Naiveof Registered Agent: ................................................................................................................................................................................ StreetAddress/PO Box: ................ I ..... I ................................................................................................... I ............................................. City/State/Zip Code: ...................................... ..................................................................................................... .............. Office Phone: ................................................... 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 p ovided herein. r �_,_, �� t" ', e_. Type or Pant Name:.......(�Y�!1-.. [/IL�+4r Title or Authority:.......... C??v l k 1 ..... `Lr�' �Ji, .... ........ ........................ .......................... I........................... cl Signature:........... ........ .... r.... ........................................... Date:....... 11/.�.7/�rtl.......... 1, .::::... .k) "1............. Q5...................................................... . a Notary Public of the County of .. ►25`� .....t'.........,......•........., State of do hereby certify that =-?" � L � ......CA..�. e.,�,.1............ appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/tier. Witness my hand and notarial seal, this .................................................................... day of .1.1.!!U1F F 20.....�.... GFif7F5r ,. , . ....�.�......... Notary Public Name:... Notary Public Signatur Via, . ...... .......i (.. a l M commission expires: ..i .1..mod. .......................... "0�1� �Un1� � ®� Y p B Lary St®® e�de�Itot18907,% Parcel # Tax Block # Tax Lot # 6833-80-1709 6415 50 6833-80-0963 6415 92 6833-70-2898 6415 120 6833-70-2994 6415 119 6833-71-2081 6415 118 6833-71-2057 6415 117 6833-71-2123 6415 116 6833-71-1199 6415 115 6833-71-1255 6415 114