The URL can be used to link to this page

Home My WebLink AboutNCC221833_FRO Submitted_202205126�861_78 City of Winston-Salem Field Operations Department � Office: WOE-. First Street. Suite 328, Winston-Salem, NC 27101 Nlailing: PO Box 2511, Winston-Salem; NC 27102 w _ 67,6q aC, Erosion Control division No person may initiate any land -disturbing activity exceeding 2G..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 threslioicls, 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 rosion Control Permit has been issued. Please type or print. Please place "NIA" in the blank- space if not applicable. �'�'-r�� I � ► �! �'l� � � 1�Sj `Q�� T a � '~ � �C�j� Part A ProjectNan1e:........`.. -... .�". . ` : ...... ` . .. `..! .....? �.` .' .. c................... :............................... GradinglErosivnControl Permit#:.............................................................................................................................�...-`.----------------------------- Location of Land -disturbing Activity: Q � E _.... .!i .u4., � �?. a...fi...�:e,(& :: j...._1..4�iA-6 P.,... ........ Latitude: _...`.... Z�................................................. Longitude:�� .. �?©:.. . ...... ............. Approximate Hate that Land -disturbing Activity will Commence:.............-...1D..&5::.... 2_........................................... Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision [gResidential Single-family Lot/Lots ❑ Other To.al Site Acreage: ............... Lo. �..... Acreage to be Disturbed: ; GradinglErosion Control Permit Fee: S ..... I TA —--------- Person to contact should Erosion Control related issues arise during lard -disturbing activities: Name: ... �.`.»UfC1L......... ........ Email: ..........C�.� 1..G 4I�.'..t. .. ........... Office Phone: ................................................... Mobile Phone: � ! !%,�- � Z � - � � � � 1=a.x Landovmer of Record: (use h1ank- page to list additional owvery iineeded ) Part el PTt\1..../�5........Tax Loin: .......................... Name:.------ Q . �4....... .................................... ...................... ... .................. Su-eet AudressFPO Boz:....... ......... ? ! (......... ...................................... ....... ... .................. _ CitviStatetZip CCQode:......... .tz �..... ..... .. .. ....................... Offfice 1'i�orte:.. (.f .-.�.." > Mobile Phone : ........... ................................... ....... Fax ;1:............ Grading Contractor Information: (ifknown at time ofsubmitting the E'msion Contral flan for review) Value of Grading Contract: S.................................................. City of WS Contractor 113 ==.... ..................................... ...................... Name of Gradine Contractor . ............... ..................... ......................................... NC License T:........ I ............ ........._. _................ Contractor Contact Person: ... .................................. ............................................ Contact Phone:.......................................................... .3(mutAddresslPQ Bux...................... ........ ..................... ............................... .... .... ............................... ................ .......... ................................... City/State,Zip Code; ....................... . ..... . ............. . ........................ . ................ . ... . .. . . . ... . ................ ....................................................... _._ FA Nit Person(s) or firms who are financially responsible for this land-disturbiug activity: (use blank page to list additional person(s) or firms if needed) *f**Contractors are not considered financially responsible for property not under their oilnership*** Name ofPerson orFirm: .//cck�' ................. StreetAddresst?O Box:.........f.�...... ....._ 4} v_ S.I = —.... `r '............................................. Uty/Statc/Zip Code :.............!.? �.E ..y.... ....._ a .........................._. Office Phone: ................................................ Mobile Phone:�.V.... Fax #: If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Name of Re`istere[Agent: ...................... StreetAddressiPOBox: .......................... . ........................................... _...._.... Ci€y/Stategip Code: ................... Office Phone: .................... ........................... .. Mobile Ph one: ................................................. Fax 0:.................. lfthe financially responsible party is a partnership, provide information for each Genera Partner: (use blank page to list additional partners if needed) Nameof Registered Agent................................................................................................................................................................................ Street AddrewPO Box:... ............ . ......... ChY/StateiZip Code: ................... Ofice Phone:...... .... ..... .................. » . ,...... Mobile Phone .................._.....--•----..............---...--- Fax #: .............. ................................... The above -MT-mmtion is true and correct to the best of any knowledge and belief and was provided b}- Inc under oath. { l ltis 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 responsibie peron-) 1 agree to provide corrected information shouid there be any chanoc in dfe infor3rfation Provided herein_ Type or Print Marne. _ k6x'l- ............................................................................. Bile orAwhority'_ _ _--- Suture:......_............t�.�............ ....................................................................... Date: .... ......i...... .............................. a Notary Public of the Countyo-f—..�.`'` i.`�...............,. State Of ....•---.1 �-•C-- ................ .. . do hereby certify that . �.l.� ......... z appeared Personally before me this day. and being duly sworn, acknowledged that the above form was executed by lfirr.77e=. -Wiiness my hand and notarial seal, iWS ........._� .[ -� day of .................................................. 2U NL Ad -Notary Public lvarrfe: .., ��• 5� T/�''•. Notary Public Sigma U MAR �� my commission expires: � .�. �� - 1!�r...... � 21 �K g,��Tq'gYEP��,.