NCC240836_FRO Submitted_20240327

_P, thy of Winston-Salem Field Operations Department 1 Erosion Control Division
Uj ofti,,x; 100 E. Fil-s1 ; t:t'4:.,..1,Snite:',::::1.!:,, Winsto»-Salcin, Di.:17101
WIISIi1011111 \tailing: PO Hos 2'')I I:, Miiiiston-Sakm,NC 27102
- - - —---- • . - . . — .... •••
Financial Responsibility/Ownership Form
Nt,person inay initi;;U, any laud-disturbing activity -..-nccedior,20,000 squo.o. ii±;.!-i hi/Single4amily Dwelling Ctinqateilim_ I 0,0il0
square feet tor any other non-excmpt purpose,or patt of a huger common phim ot development exixeding these thresholds.before this
form and an acceptable Erosion Control Plan have been Aibinined.reviewed, -trst approved by the Ciry of winsion,satem r roion
Control Division and a(Iirailing/farsion Control Permit has been i aid,7. PIC:3 S e;typ( or print.Please place'N/A"in the blank.space if
not applicable,
Part A
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Project Name: . eCCtaki ,, s f...,V(17://
(iradi rig&rosion Control Permit.P:. ftl)C74() q I ..
Location of Land-disturbing Activity' 444.4 Li le-P O.Z.- /14/
-7 1 mnolude. — St?.„ i- 1 7 7
Approximate Date that 1...and-rlisturbily.Activity will Commeno- /5
Purpose of.Grading:
0 Cot men:ial 0 Residential Multi-lin-oily n Ri::lideritial Single-family Subdivision
." Residential Sinle-family 1..ot,tots\11 1.7]Other
Total Site Aerea!:!(.... .. ...61, A.'" ,.‘,.7„.„
,..to be Disturbed!
(..iradingiErosion Control Permit Fee: $ ).),65trl•
Person to contact should Erosion Control related issues anise during land-disturbing activities:
Office Phone. Mobile Phone:VAR—,f.V.I.".. .(.CI 1 Fax"f:
Landowner of Record: (uct blank page to fist addiiionat owners Oro:Wed)
Pared PIN IP SP./ 1- 05 4114/ fax Block P• Tax Lot it .
Name: i&X.(./.0/\ rif,oW E5/4- 11 P('v' eC? irleC
Street Address/PO Box' '2.117 fr1A41,ifY1 kidil deed
•
City/State/lip Code• CA.MEYILVAS /Oa ,
Office Phone Mobile Phone. 35'6, ,d" 7/77 Fax
if. ratting toontracim. Informaii ion: (i)rknoT, s1 at Hine oicithmildna the ErtKiott ('mum/Pion/ 1'tl'A'ietuf
Value of Grading("(Attract: S City of iiVS Contractor IDA'. .
Name of Grading('cll ractoi: . Nf,..' LiCeTISC
Cointnelor Contact Vecson7 (..001.F.tel llninc
Sirecl,Adilres;NWO fox:
(.45".SIZIECI7 ip Cetti—

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) "4*Contractors are not considered financially responsible lbr property not under their ownerihip*"
Name of Person or Firm:
Street Address/PO Box:
City/StateiZip Code*
Office Phone: Mobile Phone: Fax 4.
lithe 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#:
lithe 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 lbrin
must be signed by the financially responsible person,if an individual,or their attorney-in-faer,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.
Ty.pe or Print Name:
..... ../.1.4a/G .
..
Title or Authority: IAINtlr••-•
.
Signature: . . . Date. ....
f,f, Aher a rtclez . a Notary Public of the County of, r6Y(t'k
State of..i.v.90H6 11,1 ,do hereby certify that . 61te.rd 60-re lit 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 day of 12e..ne 6-QV
Notary Public Name: r 0 irYti2
NH R L FERNA DEZ
Notary Public Signahoe• • WY*
My commission expires: . '` ‘
Expires September 18,2027
Notary Pure-
My Commiss On
• • North Carolina
or yth County