NCC216951_FRO Submitted_20211215

STORMWATER/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: BELL -PROPERTY Permit #_-_____
----------------------------------------------------------------- ---------------------------------------
___-
Location of Land -Disturbing Activity: 0 BAUX MOUNTAIN ROAD WINSTON SALEM, NC
- ----- W---------------- -------------- -------------
Latitude 36° 9' 42.19" N Longitude 80° 1
Approximate Date to Commence Land -Disturbing Activity:
Purpose of Grading: 9 Commercial
9 Other (No development proposed)
04/02/2021
9 Residential Multi -family
9 Residential Single Family lot
9 Residential Single Family Subdivision
Total Site Acreage: 25.50 ACRES ------- __ Acreage to be Disturbed:- 6.42 ACRES_____ Permit Fee:-_-��___________________________... ...............................
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name CHRIS BELL ---- E-mail address -
Telephone (336)842_9323----------------- Cell #----------------------------- Fax # --------------------------------
Landowner of Record (use blank page to list additional owners):
JOAN BELL -[phone] -_-__-
Name Owners hone #
6532 MARION GIBSON WAY
-tree---W-r_e- ------------------------------------------------
Street Address/P.O. Box
--- ----------------------------------------Owners #
---------------------------------------------------------------
Street Address/P.O. Box
OAK RIDGE, NC 27310
City/State/Zip Code City/State/Zip Code
Tax Block #: 6837-99-5594 Tax Lot #: ------------------- Zoning: RM-$---------- Zoning Approval:
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.
$ 22,000
Value of Grading Contract
J.S. EXCAVATION & LAND MANAGEMENT
Name of Primary Applicant (Grading Contractor)
Street Address/P.O. Box
WALNUT COVE, N.C.
City/State/Zip Code
City of W-S Contractor's ID #
Contractor's N. C. License Number
JUSTIN SPILLMAN CHRIS BELL
Contact Person for Contractor
[phone] [phone]
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 fums).
Contractors are not considered financially responsible for property not under their ownership.
JOAN BELL
Name of Person or Firm
6532 MARION GIBSON WAY
str1 Aaersi>P:o: Box ------------------------------------
OAK RIDGE, NC 27310
City/State/Zip Code
[phone]
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.
-------------------------------------------------------- ---------------------------------------------------------------
Name of the Registered Agent City/StatdZip Code
------------- --------------------------------------------------
Street Address/P.O. Box Daytime Telephone #
3.. Lf the_na r.jab_resptvlajWr.party is a partnership, give the name and 1dd[flSSnf cwhSaeIr:pj-e Mrr.(oe blank page to list additional
partners).
---------------------------------------------------------------
Name of the General Partner
- _i;iY Address/P.O. Box
---------------------------------------------------------------
City/State/Zip Code
-------------------------------------
Daytime Telephone #
Name of the General Partner
--------------------------------
Street Address/P.O. Box
---------------------------------------------------------------
City/State/Zip Code
-----------------------------------
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.
JOAN BELL OWNER
Type or Pri t Name-�------- -- ----------------»----_- Title--- Authority. -------------------------------------------
or
:_.,:.�-----------------------------------_J--------------------------------
Signature Date
l'----��-hhSl---- ---�� 1d1 �.t---------- . a Notary Public of the'County of G I�i u rJ----------------------------------------
State of North Carolina, do hereby certify that .......... �Fn 1�_.-----
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--h-....... day of y ...... -........ 20 p�---•
My commission expires: 1 �� ��'�_-_
ye---------------------------------
N
DOtdCdA7Carolha
llota
RandoCounty
Slate of
My Comm,1,