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Home My WebLink AboutNCC216614_FRO Submitted_20211129STORMWATER/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 County Inspections Division. Please type or print. If a question is not applicable, please place "N/A" in the blank space. PART A Project Name: Marren Permit # Location of Land -Disturbing Activity: __ Doub Rd, Lewisville, NC (PIN# 5875-50-4898.000) -_---__---- Latitude 36.081015 Longitude-80.436862 Approximate Date to Commence Land -Disturbing Activity: September, 2021 Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot es i ental Single Family Subdivisioni Total Site Acreage: _61:74 -- Acreage to be Disturbed:10.27-----__-- Permit Fee: $2,662.00 ---------------------------------------------- ----------------------------------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name J. Matthew McChesney __________ E-mailaddress mmcchesney@taylormcchesney.com S30 Telephone (336)_794-1752 Cell # (202)�94�2--- Fax # _____________________ ------------------- ------ ----------------- Landowner of Record (use blank page to list additional owners): JTM Marrin, LLC. -----------------------------------------------------------#------------------------------------------------------e Name Owners phone Name Owwnersners phone # 110 Oakwood Dr., STE 110 --------------------------------------------------------------- ----------------------------------- Street Address/P0- Box Street Address/P.O. Box -- Winston-Salem, NC 27103 ------------------------------------------------------------- ----------------------------------- City/State/Zip Code City/State/Zip Code Tax Block #: Tax Lot #• _____ Zoning: RS_40 RS_20 _ Zoning Approval: RS _20 ------------------•----------------------- Contractor Information Required Prior to Permit Issuance North Carolina State Law requires that contractors be licensed to perform work valued at $30,000 and higher. All contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. Value of Grading Contract Name of Primary Applicant (Grading Contractor) Street Address/P.O. Box City of W-S Contractor's 1D # Contractor's N. C. License Number Contact Person for Contractor City/State/Zip Code Contact Person's Daytime Phone Number |.Pemou(s) or firms who are finaoukJ page uolist additional persons or§nos)' Contractors are not considered financially responsible for property not under their ownership. JTM Menin. LLC. ----------^----------------------` ��oy��o mr�oo 11OOakwood Dr..STE110 ___,____________________________ Stme�'��remmD�.�k�o� VVinston'Ga|em.NC271O3 ------'---'--------'-----------'--------- K��/0tw�/��p�Cu�a (336)794'1752 -------------'-------- umo��o��ne# -~~~~~~~^~^-----------`-----~-----------' Name of Person or Firm ---------------------------------------------------^----------` Street Address/P.O. Box ------------------`~-----`---`---------City/State/Zip Code - -----------------'--Daytime Telephone 4 - IIf the financially responsible party is an out-of-statcresident, give the name and street address of the registered in -state agent. ____o��&m ____________Amm�__________________ __________________________________ �amn��Cdy/Stmke/ZipCode ----------------------------------------- ---------------------------- Daytime Telephone # isapartnership, give the name bkankpage oolist additional ----`—~--~--~—----~----~~--------~~-- e��a��—��a� ----~-----~-------------------^--- ��drmms0��kBu� ___________________________ _______________________ Daytime Telephone # _____________________________________ NameoKtheGemera}Partaer ________________________________ Street Address/P.O.Bos ---------------------------------------- ----------------------- City/State/Zip Code ------------------------------------ Daytime Telephone # The above information is true and correct to the best uf my knowledge and belief and was provided by me under oath. (This form must be