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HomeMy WebLinkAboutNCC230563_FRO Submitted_20230308' I City of Winston-Salem Field Operations Department I Erosion Control Division �J Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WinsmnSalem 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 Project Name:.........��....( t!C�t �J� V'f �✓......L.a....�`....................................................................................... Grading/Erosion Control Permit # . . C1 .........................................•................................................................................................................ e. Location of Land -disturbing Activity:.... /,% .... ......�:.F ` ..1�...... f ��'` irt-1. ,..... :....... � ........................ Latitude C.................................................. Longitude ::........................... ................................................. Approximate Date that Land -disturbing Activity will Commence:.......................................................... �> ............................................... Purpose of Grading: ❑ Commercial ❑ Residential Multi -family a`JResidential Single-family Subdivision ❑ Residential Single-family Lot/Lots /❑ Other Total Site Acreage:......... e..) ° Grading/Erosion Control Permit Fee: $.................................. Acreage to be Disturbed:............. /..Y.......................................... Person to%contact /should Erosion Control related issues arise during1 d-disturbing activities:q/ % Name:.....4� �. �3....C...1.�.. '...��.............. Email: ..... �. 'z �li li G GC< iu b4c.............................(C(C'la'`a / ,^ Office Phone: ' � ' . ! �� '� ... Mobile Phone ........ Fax #: .................................................................................................................. Landowner of Record: (use blank page to list additional owners if needed) ParcelPIN #:.............. •............................................................... Tax Block #:.................................. Tax Lot #:................................... Name: ...........:..r..... .`a.� .....: �:l:'.6, .................................................................................................................................................. Street Address/PO Box: �1..1. / ......r III:!; ? W Cam. G ....r r.. .�.:........ /`..........f.'•....................................................... City/State/Zip Code: '1.AS.1A'n.... LZ( ' a •% c ��.<.................................................................................... 9 Office Phone: r jl '` 1... � ..�. ��' ... Mobile Phone .............. .......�4afi....... . Fax # :................................................. Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $ .................................................. City of WS Contractor ID#:.................................................................. Nameof 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*** Nameof Person or Firm:......................................................................................................... ////%/ `/ Street Address/PO Box: ... l�l..(.1........ /I % `�� ,��. ........................................ ........ ........ .... ........................... ,� - / d2 c 7 City/State/Zip Code:.... i.L:2 ��......'............ C ................ ..............:....................J............................................ ,n �� .. �l f Mobile Phone: '°C .._ Office Phone ..... �.....�.���.................... .................. � ......................... 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: ................................................................................................................................................................................ Street Address/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. 7 ) Type or Print Name ........(/ ••%:..cw:..: Z�r`................................................................................. . 6? - Titleor Authority:.'�-........... .<:::,.,r.w.............................................................................. _...__. Signature: `---- Date: �--" ! �. -� /.7........................................... , a/Notary Public of the County of(... i:.�:a.... , State of ....! °...1� ��1(ti.14�d hereby certify that ..... `� 1K.j..9..." `Y.7 (?:.il... .. , 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 ........................1. ........................................... day of ... Cs I�LGa � .............. , 20 ...... SUSAN BENNETT t L� c�� ���r 1i Notary Public North Carolina Notary Public Name : ............................... Guilford County 1 Notary Public Signature; ................. X' :' �... �( ..� My commission expires:........................................................ Notary Seal