NCC231165_FRO Submitted_20230424

hijCity&Winston-Salem Field Operation Department Eros:on Control-DIvIroqi
• office: 100 E. Firs!! Stri L Sarine 128. Win:Qon-Salem, NC 27101
11ii�ti9fllh5i�t111 MA!iIi )lioX ? 1. Winston-Stx11,:m. \(.' '?I()?
Financial Resptornsibility/Ownership Form
No person ones tttitiniL any lancl-tltr(tubing activity exceeding?11,f0oscictari feel !Ur Single-F:°ttntl, l.)w.11tn) constrt.uction, 10,000
scp.iRre t et to any other I n-exanllit purpose,or part ni'a larger common plats o1'dlcv ett+pment exceeding th.nhe tibreshatld:s,hetC)re this
form and an neectbaahle I-::ruiion Ma submitted, reviovedt,and approved by the ('sty of Winston-Salem hm ion
C'utttrul Uiciwatt cttid a(;ra drtg'tirusiou C'orllrol Permit lab been issued. Plk.:asc type ur print. 1'I rte place"N/A"in the blank space it'
not applicable.
Part A
Project l+:atm• GLEN ABBEY SUBDIVISION
•
(iratlinglirttsaion C'i►nin 1 !email ri:
Ltirtttittat a►I'I.and-disl>�rl�i rig A ti►il;�': ....,,2363„2389,2345 PISGAH CHURCH ROAD
I.atitutlar. ..,.. 36.12808$° I.ongitudld: -$0,140939°
Approximate hate that Land-disturbing Activity will Commence. MARCH 2023
Purpose of Grading:
C1 Commercial LII Retiiiitentiol Multi-filthily lI Residential Single-iatmily Subdivision
❑ Residential Sillgls:-ftunily Lot(Lis ❑Other
fond SiseAra'en!e: .... 38.610 Acreage to be f)islttrbetl; 33.64
:iradin5;'Lrrta,iun ComrOJ Permit Ice: 5 7,235.28..
Person to contact should Erosion Control related Issues arise during land disturbing activities:
BILL YEARNS i niuil: byeams( m�tgranvillehome.00m
.u...n..+ub..ian....aua P....1..... ........,,�..wb. J I....Ju n,........ .I1" 1 B.W.....SMUN,...11.• 1/..d14u,1H..i11 1Hu
11lic.e Phone: [phone] -y... M cthik Phone: ,. Fax .
..andowner of Records (nye Mink page to list additional atiln.er8!J'r:eercleci.)
6866-37-2026 6866-37-3255
%reel PIN ,..., ,,... Ta.x. Block : Tux Lot#:
: YEARNS PROPERTIES, INC
tttt)'Ic' Y......11N1111hN11111$.......1,)H11Y 191.0111nN,ll)YM .
moo Address/PO Box! .. P.O. BOX 29341
1ity„' fttrcZip Code:, GREENSBORO, NC 27429
ace Phone: [phone] Mobile Phone:
..,....0 11.....1,..1„., lax#•
;rattling Contractor Information: (IJ- •tenure dit fifth'u/snintrilaiarl;the Erwin?, C ullom°!'danfor'review)
aloe of Grading ('otnh'uet: S City of WS Contra►ek w 11):ii:
arm of Grading('oritrae tor: • • NC License id:
ontrateLor C ontuci P.rson:..., ('cwttuct Phone:
ret.t;\a ldre►,t;r'P()13ox:
'ty. Staiu;lip Code-

Part ft
Person(s)or flouts who arc financially responsible for this land-distarhing activity: fuse blank pug,: to list a(ldhiontit
00.soom or fi rtns tirneedvil) 'olittact[Its are not dered ropotistblo,'rot proport±,. Nor moor tlin oNvo(INhipi*,.
Firm: PRO?ERYIES, INC
Name or Person or
Strvet Atittres5.-110 Box: P,O. BOX 29341
city!statezip code.. GREENSBORQ, NC 27429
Office Phone:... 1.9, .. ... Mobile Plante:
li`the financiall?,.responsible party is an oat-of-state firtn. provide Information for the in-siate registered agent:
Name of Registered.Agent•
St reel Address'PO Box'
CitylState.7.ip code:
.Plionc:*11..1..I. .. ..........•...6 Meb/le rhialle: ....it... . 4:: ....... 101..•............
If the financially responsible party is a partnership,pro%ide information for each Central Partner:
fuse blank page to list tidditignint patters.if ritealed)
Milne'(11.Reg buffed Agent:100............•............ .......11..1...........lb...... ..1.........16/1..11..11..............146.8.1.141 116.4..... .....I.......
Street Aare:N.0'0 Box:
City/State/Zip Cork;
Office Phorio:........... ....... ......... Mobile Phone:[phone].114.......41.4.1............... Pox N:4414.41.....5444011164414......6.......440.
The above flilitftflfiliOn is tole and correct to the best of my knowledge nod behe-f and was provided by 131e under oath. (This loon
rnost be. !Anted by the financially ix:span-sib:le person,ilut individual,or their attorney,in.fuet,or if not an individual,by an oflicer,
director, partner, or registered agent with authority to execute instroinents flu the:financially responsible peisia, agree to provide
corrected intimauttion should thew be any elttmgfe.in the ittibrolution provided herein.
Type or Print Name: .„ 14/11.1‘C'ti 6 Yee-0-"IJ 777
Title or Authority; ....P....K.1.'1'6............................ ......1.1411... .....1.11.1........ ..........1.11t...........6.... .......,14.$1•4.....4
Signature: ., 11..1 I • b.......b I.........44.1.........111.4..... .1.414.4 ......... Date:... . .. ... .. b b
1.
H VP4...L a Notary Public(lithe County of UILEP...,. .
State or .......„ do'hereby celify that ..........,appeared
personally.bet bre me this day,and being duty sworn, acknowledged that the above fonn was executed byhim 'Witness my
hand and notarial seal, this . . . ic day, ol t14g611 20 .Z.$
oittittle,
Notary Public Name: ....... • 141/48L8 8. frsoNtk.
4,
,?;45c11.141.%
Notary Public Signatu +0.1.4
re: .....
My commission expires: it1/4.g41-1 .2025
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