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Home My WebLink AboutNCC221391_FRO Submitted_20220413City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 M11111.MCM Mailing: PO Box 2511, Winston-Salem, NC 27102 Financial Responsibility/Ownership Form No person may initiate any land -disturbing activity exceeding 20,000 square feet for Single -Family Dwelling construction, 10,000 square feet for any other non-exempt purpose, or part of a larger common plan of development exceeding these thresholds, before this form and an acceptable Erosion Control Plan have been submitted, reviewed, and approved by the City of Winston-Salem Erosion Control Division and a Grading/Erosion Control Permit has been issued. Please type or print. Please place "NIA" in the blank space if not applicable. Part A Project Name:.Hazel Weisner Property - Erosion Control Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity: ............................................................... Latitude: ......................................................................................... Longitude: Approximate Date that Land -disturbing Activity will Commence: .............. Purpose of Grading: ❑ Commercial ❑ Residential Multi -family N Residential Single-family Lot/Lots Total Site Acreage: ............................................. Grading/Erosion Control Permit Fee: S .................... .............. ❑ Residential Single-family Subdivision ❑ Other Acreage to be Disturbed: ................................................................... Person to contact should Erosion Control related issues arise during land -disturbing activities: Name:.Hazel Weisner Email: im�4deacons -- aol:eom ......................................................................................................... Office Phone: NIA .............. .......... Mobile Phone: 336. 407-7765......................... Fax #:.NIA ........... ................... ............... Landowner of Record: (use blankpage to list additional owners if needed) Parcel PIN # :...... 587fi.53-8743............................................... ...... Tax Block #: 4612 ...... Tax Lot #:.�2. ......:.............. Name: .Hazel Weisner.........................................................................................................................................................I........................... Street Address/PO Box: ...��.7.4......G�apgy!.n�........Ro,�d City/State/Zip Code:.. w�S.vr...... &......� ZP! ............... .......... OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:................................................. Grading Contractor Information: (f k170111n at time of submitting the Erosion COntrol Plan for review) Value of Grading Contract: $ .NIA ................................ City of WS Contractor ID #: N./A ......................................................... Nameof Grading Contractor., .NIA.................................................................... NC License #:.NIA....................................................... Contractor Contact Person:.NIA................................................................... Contact Phone:.N/A.........I.. StreetAddress/PO Box. TA............................................................................................................................................................................ City/State/Zip Code: NA.................................................................................................................................................................................. Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional person(s) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm: Hazel Weisner. ............................ ......................................................... ....................... Street Address/PO Box: 8.76.Grapevine ...............Road.................................................................................................................... City/State/Zip Code:.�ewisville, NC 27023 ........................... .................................................................................................... Office Phone: N.IA.......................................... Mobile Phone:.336 407.776.5...................... Fax ....................................... .. If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: .......................................................................................................................................... StreetAddress/PO Box: ............................................................................................................................................... City/State/Zip Code: ................... ................................................................................................................................ Office Phone: ................................................... Mobile Phone:............... ......... Fax #: If the financially responsible party is a partnership, provide information for each General Partner: (use blank page to list additional partners if needed) Nameof Registered Agent: ................................................................................................................................................................................ StreetAddress/PO Box: ................... ................................................................................................................................................................... City/State/Zip Code:......................................................................................................................................... OfficePhone: ................................................... Mobile Phone:............. .... Fax #: ...................................................................................... 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 their 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 Name: .HaZel Welsner......................................................................... ............................................................. . Title or Authority- President Signature: ...... A...........................'.`'01................................................................... Date:.... /i� ...... Q ien .l. e� ................... �-- 1, ............. !!..ti .. ��...... .. .. ............. . a Notary Public of the County of...�.�............, State of ..................... do hereby certify that.....R.�..."`.�................. , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my hand and notarial seal, this ................................................................... day of ....1. �i....1�� .J��................... , 20 .... Notary Public Name- .4.............. Notary Public Signat.. ... N07ARY — U My commission expires: �....�...9.O PUBLI............................ 9 lhotaty �'al coo �11111111mll