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Home My WebLink AboutNCC230986_FRO Submitted_20230405 City of Winston-Salem Field operations Department I Erosion Control Division Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101 4411iSG1115i111'IIl 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 Pen-nit has been issued. Please type or print. Please place"NIA"in the blank space if not applicable. Part A Brook Hill Subdivision Ph ProjectName:.. ............................................................................................................................................. Grading/Erosion Control Pennit#: .................................................................................................................................................................. Location of Land-disturbing Activity: .635 Hauser Road: Lewisville, NC 27023 Latitude: .....................36.093660 -80.455128 ................................................... ........................................................ LonP,ihide: ......................................... Approximate Date that Land-disturbing Activity will Commence: April 2023 ............................................................................................................ Purpose of Grading: ❑ Commercial ❑ Residential Multi-family ® Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑Other Total Site Acrea e: . �c' ) 9.g 5$ 07 .IS. ......................... Acreage to be Dishnbed: .......350 ... .... ............................................................ Grading/Erosion Control Permit Fee: $ .................................. Person to contact should Erosion Control related issues arise during land-disturbing activities: Name: Will Derrickson ...... Email: wderrickson mun o.com......................................................................... .................. .........9....................................................I................ Office Phone: .336-231-6902 Mobile Phone: 336-231-6902 . Fax# ........................ ..... ........................... .................................................. Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN#:........6875-04-1127 .................... Tax Block#: ........4437.............. Tax Lot#:................................ ... Nang. .RS„Parker Homes LLC .............................................................................................................................................................................................. StreetAddress/PO Box:....502 HlCkorar Ride Dr. City/State/Zip Code:...Gr@er.Sbt]r0, NC 27409................................................................................ Office Phone: ....336.399-7917............... Mobile Phone: .................................. Fax#:................................................. Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for reviex) Value of Grading Contract: $ ................................................... City of WS Contractor ID#: .................................................................. Nameof Grading Contractor: ............................................................................. NC License#: ................................................................ ContractorContact Person: .................................................................................. Contact Phone: ............................................................... Street Address/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 Finu: CIa on Pro ernes Grou InC. �.............p.....ie ...........p,I,n,........................................... ................................................... Street Address/PO Box: . .....221Jo.n.esto.w.n..Rd ............................................................................................................ City/State/Zip Code: ...Wjnston-Salem, NC 27104 Office Phone: ..336-231-6902 Mobile Phone: Fax#: If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent: Narneof Registered Agent:............................................................................................................................................ Street Address/PO Box:... City/State/Zip Code:........................................................................................................................................................... OfficePhone: ................................................... Mobile Phoue: ...................................................... Fax#: ................................................. If the financially responsible party is a partnership, provide information for each General Partner: (use blank page to list additional partners if needed) Naineof 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: .....�L l.Ud ....V.-Tafld�a-n............................................................................... Title or Authority: ... 1.�.+.-..�.,.CX/�.di�,..... 1...!�Afla....bwe.1VU.LtAdAdP U Signature.......... ..... 7................ ........................................................................................ Date: ...... I, ........ F , f .. . ..� ...."` .Vz 4�-��... , a Notary Publi of the Count of.....f...0 ..f. ........... I t/ State of .. ... .. `�� ,do hereby certify that Valu.— { /� .�•'••ft .,appeared personally before me this day,and being duly sworn,acknowledged that the above form was executed by him/her. Witness my handand notarial seal,this .............................................................................. day of ...�.,!,�.a:.r ...1................................ ,20.. Notary Public Name: 6 , VJM HODS NOTARY PUBLIC Notary Public Signature: .. . '. FnR! COUNTY My commission expires: .............Z,. ...L..... ... 2-p.�.,! %*WPF N M CAROLINA