NCC233311_FRO Submitted_20231107

•
City of Winston-Salem Field Operations Department Erosion Control Division
Office: 100 E.First Street. Suite 3 2 . Winston-Salem, NC 27101
141115111IIS;IlI Ill 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: Hidden Woods Village Residential Subdivision
Grading/Erosion Control Permit It:
Location of Land disturbing Activity: 0 STANLEYVILLE DR (Pin: 6829-68-4171.000)
Latitude: 35.9128 -80.0740
Longitude:
Approximate Date that Land-disturbing Activity will Commence: As soon as permitted
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family 0 Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 16.638 Acreage to be Disturbed: 13.75
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Jose Londono Email: [e-mail]
Office Phone: Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN A.6829-68-4171.000 Tax Block#: 4951 Tax Lot#: 026B
Name: SHEPPARD INC
Street Address/PO Box: 3989 HUDDINGTON CT
City/State/Zip Code: WINSTON SALEM NC 27106
Office Phone: [phone] Mobile Phone: Fax#•
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan,lor review)
Value of Grading Contract: $ City of WS Contractor ID#:
Name of Grading Contractor: NC License ti:
Contractor Contact 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 Firm: SHEPPARD INC
Street Address/PO Box: 3989 HUDDINGTON CT
City/State/Zip Code: WINSTON SALEM NC 27106
Office Phone: [phone] Mobile Phone: •
Fax#:
if the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered Agent.
Sweet 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)
Name of Registered Agent:
Street Address/PO Box:
City/State/Zip Code:
Office Phone: 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 siened 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: Jose A Isasi
Title or Authority: President
Signature! �-vC c�, "` Date: (J z 3 - z c'Z3
I. e 142-- VO /14
� J ,a Notary Public of the County of J ityl-AS a�
State of....I4(l1114 CAI,ae h , do hereby certify that " A- 7..sA-sl— , appeared
personally before me this day,and being duly sworn,acknowledged that the above/form was executed by him/her. Witness my k
hand and notarial seal,this day of 1"1 ,20
�I
CHRISTOPHER M.WILSON
Notary Public Name: ei 7l7�L �✓1 ..L '( Nota oa dtso-North
n CountyCarolina
AlL My COMSSIOn Expires September t,2026
Notary Public Signature:
My commission expires: (9 y—0/- Z 0 2(O Nora#y Seal