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Home My WebLink AboutNCC222131_FRO Submitted_20220608City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 329. Winston-Salem, NC. 27101 i Mailing: PO Box 2311, Winston-Salem, NC 27102 Financial Responsibility/Ownership Form No person may initiate any land -disturbing activity exceeding 20.000 square &CL for Singlc-Family Dwelling construction, 10,0E square feet for any other non-exempt purpose. or pan 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 Natne: �i CO l Jw a �/e/' e rrae-e ......................i.................................................................................................................................•........................ Grading/Erosion Control Permit #: N �� 0 0 b. LU........................................................ .................. Location of Land -disturbing Activity ....................... .... ��!?{ t'X �Jfd.rrl.......rf'Gj G.......................................................... Latitude: y 3 7 3� . s 3 3% .. Longitude: U. o Approximate Date that Land -disturbing Activity will Commence A -2 T -2 2— Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision Residenntial Single-family LovLots ❑ Other Total Site Acreage :....... 1..:.0................................... Acreage to be Disturbed:..... 0,'.. `........................................... Grading/Erosion Control Permit Fee: S ..,.,. 82Q .............. Person to contact should Erosion Control related issues ariseduringland-disturbing activities: Name:.....4 Pt ..... (f l e'^ evrt ............................ Email:.... .G y1 ► ►� ( ....4. 1..:. GQ/+?............1...............,................ Office Phone:... 3 S �:l �s'..... Mobile Phone:.. ��.:s's:�.3S..l,,S.......... Fax 'V .............................. .....................•... Landowner of Record: (use blankrage to list additional owners if needed) Parcel PIN n#:f.....-.[...1...-.5"_.11.SYS±...Q.D............ Tax Block #:.................................. Tax Lot #:................................... Name:... r/..`� ............C&'It................................... Street Address/PO Box:.. 2�.7..... Ar,.on.... %�Or r[ ��........c............................................................................................ City/State/Zip Code: .-Af,l.G(�IS_.......,GrC� ./..... !/.-G...............r2. 1 ............................ Office Phone. 134 .�� .... Mobile Phone:.... J?.3�• : � Sts.. Fax #:............ ......................... Grading Contractor Information: (ifknoti-n at time ofsubmitting the Erosion Cont,ol Plan for- review) Value of Grading Contract: S ................................................... City o€WS Contractor ID #:.. Name of Grading Contractor: ............................................................•------ I.... NC License #:................... Contractor Contact Person:......................................................... Contact Phone:............................................................... StreetAddress/PO Box. ......................................................................................................................•--.............I City/State/Zip Code: .............................................................................................................................. .................... Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank pace to list additional person(s) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** ) Natrte of Person or Firm: ft J l L. �- (• t�M'+�rg Street Address1P0l3ax: �Ur�ean i°ii /) L ` G ....f'............................... ............................ ...............................j............. CitylState%Zip Code:....P:.G::.....o270d............ ...................•........... ............. .............. ............. ............... ...— .. c � 3S! ... Mobile Phone: 36 ...... Fax #:........ I............. r Office Phone: ............................... If the financially responsible party is an out-of-state faun, provide information for the in -state registered agent: Name of RcgistercdAgeat:.................................................................................... Street AddresslPO Box: .......... ..................... ......................................... ............... City/State/Zip Code: ................................. ...................... ............ .................. ...................... ....... ........................... 011icePhone: ................................................... 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) Name of Registered Agent: ......................................... Street Address/PO Box: ....................................... . CitylStatelZip Code: ............................................ Mobile Phone: ...... Fax ##: OfficePhone:................................................._.................................. 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 aft 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.) l agree to provide corrected infointation should there be any change in the information provided herein_ w r ..................................................................... Type or Print Name: P Title or Authority: Pre, -S•`• .''. .. Signature:.. ............................................................... Date: ......2...................... 1,......t........-C�L'............................................... . a Notary Public of the County of..4L`Crl ^.... State of ..... .r... -. do hereby certify that .C- . ... ...................... . appeared personally before me this day, and being duly swom, acknowledged that the above farm was executed by him/her. Witness my hand and notarial seal, this Z� . day of .. � �` Q!( .......................... . 20 Z . .............................................. Notate Public Name: t-4�.......1'.. ......... G Notary Public Signature: .................. My commission expires: .C�1.�3Q..1. 7 5.......................... KARA PROFIT Notary Public - North Carolina Rockingham County My Commission Ezpfres Jan 30, 2025 Notary Seal