NCC240452_FRO Submitted_20240220

01 City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101
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 conunon 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: C'(? gr-dpo rra .pc
Grading/Erosion Control Permit#.
Location of Land-disturbing Activity: /7'42 PlicW 4 (..4.2-1-"574-pi.._ Seth r-c_
Latitude: 3Ce ? cc- Longitude: — 3 So 6 y2_
Approximate Date that Land-disturbing Activity will Commence: 2- .2(C c2
Purpose of Grading:
E] Commercial D Residential Multi-fainil D Residential Single-family Subdivision
kir esidential Single-family Lot/Lots IA Other
Total Site Acreage: • 02'49 Acreage to be Disturbed: C)
Grading/Erosion Control Permit Fee:
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Y"4-4,
OfficePhone:-3.g"- 9 %r De— Mobile Phone: Sic.- ( Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN 2-49- 796'( Tax Block Tax Lot CaP
/11/ c,A,c, 7;2 e-
Name:
Street Address/PO Box: ////,..5)/feat /(5.*/ (.22 (=LI-
City/State/Zip Code. .6.6 ?loev hoi-- 6-/c.27'/c)
Office Phone: 33<2 -6,4 6 Mobile Phone: ..Z6' Co -515 g Fax#:
Grading Contractor Information: (if biawn at tune of submitting the Erosion Control Plan for review)
Value of Grading Contract: S 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) ***Contra tors are not considered financially responsible for property not under their ownership***
Name of Person or Finn. I e 4, c> __4, ,
Street AddressPO Box: //7/C.5 fre4,-K-54-e-c-) /( gli AA IV /7 2-
citrStateiZip Code' /49(11,6/IQ/1_ .5*ce. fe Pg"---- /)"7 c A77(4, /
Office Phone:53(=" -ee5-. V.3 6? OZ. Mobile Phone: 33 4' - et-°/ - $ C=.4Fax'4.
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/StatelZip Code:
Office Phone: Mobile Phone: Fax 14.
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 sinned by the financially responsible person,if an individual,or their attorney-in-fact,or if not an individual,by an officei.
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: .. -e>.(rIV- -1,7 14-64-- 11--e-
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Title or Authority. (Pre-5 I CA e
Signature: 64"1"Z(r— : Date: ....2..../.3......,.,?..r.............
I. cu, , Notary Public of th State of in of..
. ... ..... ii.......... ekt.<1., , do hereby certify that
*-19-4)1 , appeared
personally before me this day,and being duly sworn, acknowledged that the above form was executed by himiher.Witness my
hand and notarial seal.this . ,)....-'2, A day of .fillAU..04)-'( 20
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Notary Public Nan e: ...0.. c.a. ,d,, ,
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Notary Public Signature: k-, E covOss" E
My commission expires:
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