The URL can be used to link to this page

Home My WebLink AboutNCC230176_FRO Submitted_202301200 0 City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WHSIN-Salem 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 "N/A" in the blank space if not applicable. Part A PrName: South. . ..... F...o.rk..Village.........P.hase......1 oject ...................................................................................................................................................................... Grading/Erosion Control Permit#:.................................................................................................................................................................. 5894-84-8509, 5894-84-4797, 5894-94-2408, 5894-74-7640 Location of Land -disturbing Activity:................................................................................................ Latitude:...36:0627°................................................................... Longitude: ... -80.3590° ........................................................................ Approximate Date that Land -disturbing Activity will Commence: ...1011 /2022 ......................................................................................................... Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 25.10„ Acreage to be Disturbed: 24.50 ................................................................................ Grading/Erosion Control Permit Fee: $.................................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Name:.... Kat Lyons ....................................................... Email: kat.lyons a01eoterradevelopment.com ............................................................................................. Office Phone: Mobile Phone: 336-682-14.1.4..................... Fax 9:... n/a n . a ........................................ ................ Landowner of Record: (use blankpage to list additional owners if needed) 5894-84-8509, 5894-84-4797, 5894-94-2408, 5894-74-7640 & Portion of 5894-94-7979 ParcelPIN#:.................................................................................. Tax Block #:.................................. Tax Lot #:................................... Name ....LeoTerra Peace Haven, LLC Street Address/PO Box:...11.. A Shields Park Drive ............................................................................................................................................................ City/State/zip Code:.... Kernersv.ille ..North......Caro.lina...27284.. ....................................................................................................................................................... Office Phone: 336-279-7280 Mobile Phone Fax # ........................................................................................................................... Grading Contractor Information: (f known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $................................................... City of WS Contractor ID#:.................................................................. Name of Grading Contractor: ............................................................................. NC License#:................................................................ Contractor Contact Person: .................................................................................. Contact Phone:............................................................... StreetAddress/PO Box: ..................................................................................................................................................................................... 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 person(s) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm:. LeoTerra Pea.ce..Haven...,.LLC................................................................................................................... . StreetAddress/PO Box: ..1.10-A Sl .hie.ds.....Park..........Drive.............................................................................................................. City/state/zip Code:.. Kernersville., .NC...27284............................................................................................................................ Office Phone:.336-279-7280 Mobile Phone:...336,486-3653 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: ...................................................................................................................... ............................. ...... 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. 336-486-3653 C.1.r�5�n �er OnS............................................................................................................ Type or Print Name:../.�.................?.. ...........�... . Titleor AuthoM .... ............................................................ ............................................................. Date:Signature:.......................................................fda1 1, ....... � P. ,�........7*4....... !fin! ................................... . a Notary Public of the County of ...l...!.a.l b n.......... State of .N..�� .... A-qA,..... , do hereby certify that .............r.i5 h Lo�� appeared ?... ......5:............... personally before me this day, and being duly sworn, acknowledged that the above ffoorm was executed by him/her. Witness my hand and notarial seal this 8 ......... day of ! - `&rG 20 ��.................................................................................................. , YE Notary Public Name: .R` 9b�� !�`yri L".+ t�� ¢ ire ..... .......... tic Q = ¢0 Meckle a rg p $ Notary Public Signature: ILQ. .'�/.�..: ................. ......... .. �� County My Comm, ExP x �� afla3 My commission expires: ............................................................ 0