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Home My WebLink AboutNCC217111_FRO Submitted_20211222STORMWATER/EROSIQN CONTROL DIVISION 100 Fast First Street, Suite 328, Winston-Salem, NC 27101 Financial Responsibility/Ownership Form Erasion 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 "NfA" in the blank space. PART A Project Name: Q � �-f;q_�1----�4R+S es143� v -5_k0 ") Permit # Location of Land -Disturbing Activity: ? t C7. F( __ �+��i K___ 1�p,---- � 69Sv \ L LE C - -__ --------------------------4------------------------------ L.atitude 3 . l 30 L Longitude Approximate Date to Commence Land -Disturbing Activity: 515v k,\I; e2. z t Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot 9 Residential Single Family Subdivision Total Site Acreage: 2 S. `l I Acreage to be l� '} Permit Fee: ------------------------------ ________----- : _`lE_2 $_. ---------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name ltckltrl�L _T _11 �P---------- L-mail address ! tk6A.A-. m2 vk_f_(? q +tickiA Caves Telephone ,� la ` Z �o �g Cell #-------------- Fax Landowner of Record (use blank page to list additional owners): C�i Nta_ lr`1��oA Lt►�y�� ._-- ql� 4°_8 Sz►k --------------- ---------------- Name Owners phone # Name Owners phone # Street Address/P.O. Box ______________ -------------- City/State/Zip Code -_-_ Tax Bloch #: 5�kOO - Tax Got #; Okoo / t21Q ---------------------------------------------------------- Street Address/P.O. Box ----- --------------------------------------------------------------- City/State/Zip Coate Zoning: ------------------- Zoning Approvai: Contrarlor 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_ S 570o, Oao Value of Grading Contract — M 'T` Mu_-e1�`t (,o os'%QGT,o+J (_0 T—t.]C Name of Primary Applicant (Grading Contractor) a Street Address/P.O. &3x 1`ZA�L�tGcEt . QC_ Zn 61 S City/State/Zip Code City of W-S Contractor's ID # °l Lks S Contractor's N. C. License Number �1�G41EL4 T �cs(t +� Contact Person for Contractor Contact Person's Daytime Phone Number PART B I. Person(s) or firms who are financially responsible for hiss land -disturbing activity (use blank page to list additional persons or firrns). Contractors are not considered financially responsible for property not under their ownership. SL\PPS Ei. Name of Person or Firm 'J�d -%'V, ___ °l o `_'.2.-j _ -- --------------------------------- Street AddresslP.O. Box City/State/Zip Corse ��q - $y6 - 2a(. Daytime Telephone # ----------- ------------------------------------------------ Name of Person or Firm --------------------- ----rs__-_____---__---_-__ Street Address/P.O. Box --------------- ----------------------_--______-_---____ City/State/Zip Code ------------------------------------- Daytime Telephone # if the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. ------------------------------------------------- _ __ ________ Dame of the Registered Agent __------ ____ Street AddressllP.O. Box ------------------------------ City/State/Zip Code --------- ----------------------------------------------- Daytime Telephone # ------ 3 athe is a partnership, give the name ancf ; die h e��a cl e blank page to list additional partners). ___________________________ 1Vame ofthe General Partner --------------- ------------------------------- --------------- Street AddresslP.fl. Bax --------------------------------------------------------- City)State/Zip Code -----' Daytime Telephone #------------- ----------------------- ------------------- Name of the General Partner -------A-------_----------------------------- Street Address/P.O. Box --------------------------------------------- CitylStatel2ip 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. Type or Print a ---------------------------------------- Title o� Antl�rity ------ Sig ature - -------------------- ----------------------------- Date ---- a Notary Public of the County of ''�S C�) ��-- -------------------------------------- State of North Carolina, do hereby certify that ___ncVL -- 4-- ---= � V��rP � ------------ ---- ------------------------------- } appeared personally before me this day and being duly swcrs acknowledged that the above form was executed by him. Witness my hand and notarial seal, this ___, , _____{say of 20 ----------------------------------------------------------- Notary Public My commission expires: - _S " Zi