The URL can be used to link to this page

Home My WebLink AboutNCC216659_FRO Submitted_20211201STORMWATER/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 fbet 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: Cottage Hill Stream Crossing and Private Drive Permit # Location of Land -Disturbing Activity: 906 Gibb Lane Latitude 36.1187 Longitude-80,3343 Approximate Date to Commence Land -Disturbing Activity: November, 2021 ---------------------------------------------------------------------- Purpose of Grading: Commercial Residential Multi -family Other (No development proposed) Residential Single Family lot Residential Single Family Subdivision Total Site Acreage: 4.24_________________ Acreage to be Disturbed:3.59 Permit Fee: Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Justin Mendenhall Justin@ardenhomes.com ---------------------------------------- ----- E-mail address --------------------------------------------- Telephone ---(336) -659-9503 (336) 414-5124 ---------------------------- Cell #----------------------------- Fax # -------------------------------- Landowner of Record (use blank page to list additional owners): 806 Gibb Street, LLC (336) 659-9506 - ------------------------------------------------------------- Name Owners phone # Name Owners phone # Post Office Box 5323 --------------------------------------------------------- ----- --------------------------------------------------------------- Street Address/P.O. Box Street Address/P.O. Box Winston-Salem, NC 27113 -------------I--------------------------------_---------------- -:------------------------------------ City/State/Zip Code City/State/Zip Code Tax Block #: 3467C Tax Lot #: Zoning: - 027 028 029 RS-9 Zoning Approval: _ __ _______ _ _ - ----------------- ------------------- PIN: 6806-64-0766; 6806-64-3707; 6806-64-4746 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/State/Zip Code City of W-S Contractor's ID # Contractor's N. C. License Number Contact Person for Contractor Contact Person's Daytime Phone Number PART B 1. Person(s) or firms who are financially responsible for this land -disturbing activity (use blank page to list additional persons or firms). Contractors are not considered financially responsible for property not under their ownership. 806 Gibb Street, LLC ----------------------------------------------------- Name of Person or Firm Post Office Box 5323 ------------------------------------------------------ Street Address/P.O. Box Winstonn-Salem, NC 27113 -------------------------------------------------- City/State/Zip Code (336) 659-9503 Daytime Telephone # ---------------------------------- ---------------------- Name of Person or Firm --------------------------------------------------------- Street Address/P.O. Box -------------------------------- City/State/Zip Code ------------------------------------- Daytime Telephone # 2. If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. --------------------------------------------------------------- --------------------------------------------------------------- ame of the Registered Agent City/State/Zip Code ----------------------------------------------------------- --------------------------------------------------------------- treet Address/P.O. Box Daytime Telephone # 3 _Lfthr,-5 nciaUy_[espDnsible pmly is a partnership, give the name and�sidt�sssifeaehS'cener�l�artnerl�se blank page to list additional partners). ------------------------------------- ------------ -------------------------------------------- -------------- Name of the General Partner '------------------ Name of the General Partner ---------------------------------------------------- - --------------------------------------------------------------- Street Address/P.O. Box Street Address/P.O. Box --------------------- --------------------------------------- --- -------------- - Co------------------------------------------- City/State/Zip Code City/State/Zip Codee ------------------------------------ ------------------------------------- Daytime Telephone # Daytime Telephone # 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 his 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. Stuart C. Parks �,! i% r , -------------------------------------------------------- _�i}_(, "/ Type or Print Name ----------- - ---------------------------- Title or Authority Signature ------------------ ------ -- --------------------------- Date ---------------- 10-04a--L------ ------------- , a Notary Public of the County of State of North Carolina, do hereby certify that __-_C_ appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this j_5�---_day of lA G>yj �'j______, 20 2 --�'�.._9_�J�2-------------------------------------- Notary P lic My commission expires: Qt;��j�_�,g�t�,l_____ TONYA L. WARD Notary Public, North Carolina Cabarrus County My Commission Expires October,28, 2021