NCC240022_FRO Submitted_20240104

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I °Z City of Winston-Salem/Forsyth County Inspections Division
a s 100 E. First Street, Suite 328, Winston-Salem, NC 27101
INSPECT ONS •
DIVISION
Financial Responsibility/Ownership Form
Erosion Control Ordinance
No person may initiate any land-disturbing activity exceeding 20,000 square feet for a single-family dwelling or 10,000 square
feet for any other purpose,before this form and an acceptable erosion and sedimentation control plan have been completed and
approved by the Erosion Control Section of the City of Winston-Salem/Forsyth County Inspections Division. Please type or
print. If a question is not applicable, please place"N/A"in the blank space.
PART A
Project Name: Lot#1 Marrin - Spec Permit# EN2300306
Location of Land-Disturbing Activity: 501 Doub Rd. Lewisville, NC 27023
Latitude 36.0821 Longitude -80.4353
Approximate Date to Commence Land-Disturbing Activity: 1.15.2024
Purpose of Grading: 9 Commercial 9 Residential Multi-family
9 Other(No development proposed) ®Residential Single Family lot
9 Residential Single Family Subdivision
Total Site Acreage: 1.44 Acreage to be Disturbed: 0.93 Permit Fee:
Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tim Fox E-mail address tim [e-mail]
Telephone N/A Cell# (33.6.)..345-Q64.3 Fax# N/A
Landowner of Record(use blank page to list additional owners):
Homes by Jonathan Lee, Inc. [phone]
Name Owners phone# Name Owners phone#
2235-C Lewisville-Clemmons Rd.
Street Address/P.O.Box _ Street Address/P.O.Box
Clemmons, NC 27012
City/State/Zip Code City/State/Zip Code
Tax Block#: 4438D Tax Lot#: 001 Zoning: ...RS20 Zoning Approval:
Contr ctor Information Required Prior to Permit Issuance
Northarolina State Law requires that contractors be licensed to perform work valued at$30,000 and higher.
All contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office.
$25,000 80186
Value of Grading Contract City of W-S Contractor's ID#
Homes by Jonathan Lee, Inc. 38619
Name of Primary Applicant(Grading Contractor) Contractor's N.C.License Number
2235-C Lewisville-Clemmons Rd. Jonathan Lee
Street Address/P.O.Box Contact Person for Contractor
Clemmons, NC 27012 [phone]
City/State/Zip Code Contact Person's Daytime Phone Number

PART B
1.Person(s)or firm(s)who are financially responsible for this land-disturbing activity(use blank page to list additional persons or firms).
Contractors are not considered financially responsible for property not under their ownership.
Homes by Jonathan Lee, Inc.
Name of Person or Firm Name of Person or Firm
2235-C Lewisville-Clemmons Rd.
Street Address/P.O.Box Street Address/P.O.Box
Clemmons, NC 27012
City/State/Zip Code City/State/Zip Code
[phone]
Daytime Telephone# Daytime Telephone#
2.If the financially responsible party is an out-of-state resident,give the name and street address of the registered in-state agent.
Name of the Registered Agent City/State/Zip Code
Street Address/P.O.Box Daytime Telephone#
3.If the financially responsible party is a partnership,give the name and address of each General Partner(use blank page to list additional
partners).
Name of the General Partner Name of the General Partner
Street Address/P.O.Box Street Address/P.O.Box
City/State/Zip Code City/State/Zip Code
ti
Daytime Telephone# Daytime Telephone#
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 his 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 b an change pe in the information ovided herein.
there bp
1.4ti LE-c-
Type or r nt N.:. tt,t Lc( Title or Authority
Signs Date
I, C LU�a I Notary,a Public of the County of
State of North Carolina,do hereby certify that
appeld personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this day of � .20 .
Net y ublic
My commission expires: \\\•,\ U
TASMIA R THORNTON
Notary Public
ForsythHE Co.,North Carolina
My Commission Expires Nov.14,2026