NCC232109_FRO Submitted_20230714

hi) City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E First Street, Suite 328,Winston-Salem,NC 27101
\\inslbn&Ilem Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial Responsibility/Ovynership 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 p rt 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 ofWinston Salem Erosion
Control Division and a Grading/Erosion Control Permit has been issued. Please type or print. Please place "VIA"in the blank space if
not applicable.
Part A
Protect Name: 744 Surrey Path Tr
Grading/Erosion Control Permit#:
Location o fLand-disturbing Activity: see attachment
36.10040 -80.351730
Latitude-. Longitude-.
Approximate Date that Land-disturbing Activity will Commence: 6-1-2023
Purpose ofGrading:
D Commercial D Residential Multi-family D Residential Single-family Subdivision
IiYResidential Single-family Lot/Lots D Other
Total Site Acreage: 0 1' 0 r
Acreage to be Disturbed:
Grading/Erosion Control Permit Fee: $ 106•°o
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Tommy Hedrick Email- thedrick.dreambuildersws@y gmail.com
Office Phone: [phone] Mobile Phone: [phone] Fax#, N/A
Landowner of Record: (use blankpage to list additional owners ifneeded)
Parcel PIN#: 6805-08-3007.000 Tax Block#• Tax Lot#:
Name-. Dream Builders WS Construction LLC.
Street Address/PO Box: 8603 N.NC Hwy 150 Suite D
City/State/Zip Code-. Clemmons NC 27012
Office Phone: [phone] Mobile Phone: [phone] Fax#. N/A
Grading Contractor Information: (ifknown at time ofsubmitting the Erosion Control Planfor review)
Value ofGrading Contract:$ 10,000 City ofWS Contractor ID#:
Name of Grading Contractor: Jack Moore Grading NC License#:
Contractor Contact Person: Jason Moore Contact Phone: .....3.a6._924:b5.02
Street Address/PO Box. Po Bum 375
City/State/Zip Code: Tobbaccoville NC 27050

PartB
Person(s) or firms who are financially responsible for this land-disturbing activity: (use blank page to list additional
person(s) or firms ifneeded) ***Contractors are nit considered financially responsible for property not under their ownership***
Name ofPerson or Firm: Dream Builders WS Construction LLC.
Street Address/PO Box: 8603 N.NC Hwy 150 Suite D
Clemmons NC 27012
City/State/Zip Code:
Office Phone: [phone] Moqile Phone: [phone] Fax#: N/A
If the financially responsible party is an out-of-state firm, provide information for the in-state registered agent:
Name ofRegisteredAgent:
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:
(nc blank page to list additional partners ifneeded)
Name ofRegistered Agent: Robert S Wooten
4001 Country Club Rd
Street Address/PO Box..
City/State/Zip Code: WS NC 27104
Office Phone: [phone] Mobile Phone: [phone] Fax#: N/A
The above information is true and correct to the best ofmy 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 ifnot 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: Robert S Wooten
Title or Authority: Member Manager
Signature L .. Date-. 5-30-2023
t�1c�t;(- 1 Zt'f 1'11�r� ,a Notary Public ofthe County of-040
State of NC ,do hereby certify that (Rokf l-o o ,appeared
personally before me this day, and being duly sworn, acknowledged that the above formwas executed by him/her. Witness my
hand and notarial seal,this .3Q day of ...01Q,L J ,20
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Notary Public Name: a 5 sr, • scion
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Notary Public Signature: j !L�'1���. ��:c� OlA��' wn'. �
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