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Home My WebLink AboutNCC223464_FRO Submitted_20221006City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 11lf15100-Sall91 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, 10,00o 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:............eters Creek Storage t ........ ................................................................................................. ............................. Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity: ....... 3775 Peters..Creek. Parkwa .y ............................ Latitude:...........36:01879 ... Longitude:-80.26038 Approximate Date that Land -disturbing Activity will Commence. Max 2022..... ...................... Purpose of Grading: x❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage ... . �. Ac ......... Acreage to be Disturbcd:.........2262 Ac.......................................... Grading/Erosion Control Permit Fee: $ 1046.00 ........I .................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: ....... AT. Sandkno ................................................ Email: im sandkno leoterradevelo nnent com 1.....:...............1?.......................... P.........:...............................-----.. Office Phone ...... Mobile Plione:..336.372 .17I6 Fax #: Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #:............6822; 57-8877 ........ Tax Block # ... Tax Lot 4:..................... .................................................................................. .............. Name: LeoTerra Peters Creek.LLC ........................................................................................................................................... ...... •. Street Address/PO Box: ..... 110-A Shields Park Dr. City/State/Zip Code: ........... Kernersville .....NC..27284................. ... ...... .. .... . Office Phone: . Mobile Phone: ..... 336.671.i858 . Fax #.................................................. Grading Contractor Information: (iflaimim at time ofsubmitting the Erosion Control Plata for reviei•i) Value of Grading Contract: $................................................... City of WS Contractor ID #: ..... ....................................................... ...... Name of Grading Contractor:... LeoTerra . NC License #' ]irn Sandkno .... Contact Phone 336-362-1716 Contractor Contact Person: ................................P............................................................................................................ Street Address/PO Box . ............ I 10-A Shields Park Dr. .............................................................................................................................................................. City/State/Zip Code: ................. .......................................................,......................................,.............................,......,............. Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional persons) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Finn:....... LeaTerra Peters Creek LLC Street Address/PO Box: .......... 1.10 ;A Shields Park Dr. ..................................................................................... City/State/Zip Code: ............. Kernersvil... NC 27284 ........ ... ..N..,27..............................------............................................._.......................... Office Phone ... Mobile Plione:.........336.671-1858 ... Fax #: If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: .................................................................................................. ........ ...................................... Street Address/PO Box: ....................................................................................... City/State/Zip Code: ........................................................................................................................................................... OfficePhone: ................................................... 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: Christopher (Buddy) Lyons Titleor Authority :. ...... ..... ana$th er................................................................................................................... Signature: ..........................................:................................................................................... Date:.... �J. 1%. .. ...................... I, ............... rl n rLci...S.�f.L''IG'.C. & ...... .............................. , a Notary Public of the County of ...... 7vit { '(01 .., State of ....(O fAnS...... , do hereby certify that ......... ��X..LS'��Y r..�„y�.!'!.5................. , 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...............................`...h............................... day of ....... M.r^.'(.............................................. , 20 .7Z.. Notary Public Name: ....... PI✓.t!:>w............. 5.cl. Notary Public Signature:................................................... My commission expires: .......... 1..�.y...L .................. SANo 0 o..`'°n..;o = �AOTAR ), 49 . a G7 l PUBLIC � � Notay> See [IIG pRD COV`-.�`, ,'If III 111 F I N 1111�1j1`'