NCC233650_FRO Submitted_20231211

iI City of Winston-Salem Field Operations Department Erosion Control Division
Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101
IlinstonSalem 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: /44Clei./2 Alf/ifoc,s A ,ifses
13
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: C'hikk,(M,‘ PI( A
Latitude: 3(6,- . (00, Longitude: 51±),. „Thelf)
Approximate Date that Land-disturbing Activity will Commence: jialti vb*S 2( 2.0 z
Purpose of Grading:
1=I Commercial El Residential Multi-family Itirresidential Single-family Subdivision
El Residential Single-family Lot/Lots CI Other
5—
Total Site Acreage: F. Z— Acreage to be Disturbed: e 1631
Grading/Erosion Control Permit Fee: $
Person to contact should Erosipn Control related issues arise during land-disturbing activities:
Name: 174"4:144-r Email: Eg C-14 ee/ 424-- A/e • CCSY11
r•
Office Phonc:334.1106.9 Mobile Phone: 33 (2 9'°8 /1°3 Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN #: $119 - za-7354 Tax Block#: Tax Lot
Name: -Nile'?
Street Address/PO Box• I
City/State/Zip Code: IA) • AC Z2
Office Phon3 4°6 ti3d3 Mobile Phon314:t 92°3 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#:
Name of Grading Contractor: NC License#:
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***
Nit c of l raon or-firer: 13 t44 l'A= 14 r? l C
Street Address/PO Box: I cio s5. 624-gli. y
I,.)- S /NI-C 27 Z
City/State/Zip Code: �/-
Office Phone:j odY� YOB 9-7°3 Mobile Phone:33`!' cf46 .[Q
Fax#:
If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered Agent.
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:
(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 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�f there be any change iniw the information provided herein.
Type or Print Name: .....i.l..t� �-ng�Y'Qe11--
Title o• on y: .. VVeP
7i 7 a/,s/7211G, ]cYJ
Signature: Date: I2171 a
I, B..c- 'l g c e y , a Notary Public of the County of Oct_V 1 e
State of...lV.o.}. ..20-r U I:0 a- , do hereby certify that R 4 J n c V C e e k_ , 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 4-4-- day of .C2 .,.l....A-C-L---771..:(.J-� ,20 a..
M ace7 ...............•.....++.wmiti
BETH MACEY
Notary Public Name: .. 4!c.�� / NOTARY PUBLIC
Davie County
Notary Public Signature: Ge 441 rn 4 C.C. North Carolina
My Commission Expires April 28,2028 1
My commission expires: L .<Q,..i... ...a I' Notary Seal