HomeMy WebLinkAboutNCC220427_FRO Submitted_202201219
City of Winston-Salem/Forsyth County Inspections Division
r 100 E. First Street, Suite 328, Winston-Salem, NC 27101
INSPECT OHS
DIVISION
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: Cliffdale Woods Permit
Location of Land -Disturbing Activity: .....O..Cliff..d,ale. Drive Winston-Salem NC .......
......... .....................................................................................................
Latitude 36 OMB Longitude -80,3119
Approximate Date to Commence Land -Disturbing Activity: »„»
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: 14.60 Acreage to be Disturbed: 4,83....... Permit Fee:
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name .... WIII Derrickson E-mail address
wderrickson%c�mun.9o:com...........„.„..
Telephone....33.6-23.176.76.7........................ Cell #.... 336n9.7..9-4054................. Fax #
Landowner of Record (use blank page to list additional owners):
.Clayton..Properties..Gro.up..lnc.D i .Sh.ugart„Homes
Name Owners phone #
221 Jonestown Road 336-231-6767
..........................................................................................................................
Street Address/P.O. Box
Winston-Salem, NC 27104
....................................................................... I ....... ...... _..._........ ....-...................
City/State/Zip Code
Tax Block #: Tax Lot #:
.................... .............. ................... .......... ........ ........ ...... ................ ........ P..............
Name Owners hone #
'..... ..».........................................................
Street Address/P.O. Box
.............. ..,................ :.......................................................................................
City/State/Zip Code
Zoning .................................... 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.
Value of Grading Contract
Name of Primary Applicant (Grading Contractor)
Street Address/P.O. Box
82093
City of W-S Contractor's ID #
81396
Contractor's N. C. License Number
Will Derrickson
Contact Person for Contractor
336-979-4054
City/State/Zip Code Contact Person's Daytime Phone Number
PART B
1. Person(s) or firm(s) 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.
Clayton Properties Group Inc. DBA Shugart Homes
........................................................ .............. -...... ............. .. ..... ..........................
Name of Person or, Firm Name of Person or Firm
221 Jonestown Rd
.....::.....................................----.............................................,,.,...............................1....................
Street Address/P.O. Box Street Address/P.O. Box
Winston-Salem, NC 27104
City/State/Zip Code City/State/Zip Code
336-765-9661
..-. .....................................................
Daytime Telephone # 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.
............................................. I ..................:........
Name of the Registered Agent
. .. ..:................ .
Street Address/P.O. Box
I .................. ....... »....... ........
City/State/Zip Code
..........ti...........
Te........le...........ne....# .......
Dayme pho
3:.I...the.f naneiallX responsible.party is a partnership, give the name and address of each General Partner .. (use blank page to list additional
....................................................
partners).
.....................................................................................:.:..................................
Name of the General Partner
Street 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
shoW there be any Acajnc in the information provided herein.
........................................................................ ....................
Typ or F int Name Title or Authority
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Signature Date
I' .--- l....� :...M.aff................ , a Notary Public of the County of ..........dz�SIYt.. .........................
State of No Carolina, do hereby certify that
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 ..........1. day of ..... , 20'.
....
/ Nat ublic
... ... .7
My com.. .. . ... ... - o
mission expires:1. ''�`/"/„
Eco
ANGEL G. HIATf
tary Public - North Carolina
Forsyth CO ty
mmission Expires