HomeMy WebLinkAboutNCC241049_FRO Submitted_20240408 i City of Winston-Salem Field Operations Department I Erosion Control Division
�J Office: 100 E.First Street.Suite 328.Winston-Salem,NC 27101
fill11114.111 Mailing: IN)sox 251 I.Winston-Salem,Nc'27102
Financial Responsibility/Ownership Form
No person may initiate any land-disturbing activity exceeding 20,Ot01 square feet for Single-Family Dwelling construction.10,000
square feet for am other non-exempt purpose.or parr 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 GradingFroston Control Permit has been issued Please type or print Please place"N/A"in the blank space if
not applicable
Part.a -
Project Name:.... O . ........ .fc icrt to+
Grading/Erosion Control Permit N:
Location of Land-disturbing itiVitt,celcde
latitude:.3C. Longitude: — CO. O 3 3 g577 _ _m
».
Approximate Date that Land-disturbing Activity will Commence: 11'
I f.. •
Purpose of Grading:
❑Commercial ❑ Residential Multi-family
0 Residential Single-family Subdivision
Residential Single-family Lot/Lots ❑Other
Total Site Acreage:... 3. Acreage to be Disturbed: • G
Grading'Erosion Control Permit Fee: S
Person to contact should Control related issues arise during land-disturbing activities:
(L
Name:is I /Y I `i .„.. Email: W'11. ce°44 ou'14 Wv'l�s(A9 o?.:bus v
Otbcc Phone: »......... ................ ... Mobile Phone: 3 F-3 0►'3r 93 Fax N:
Landoss nrr of Record:(use blank page to list additional owners if needed)
Parcel PIN 0: 61 'j 1 ,.3?.?‘ Tax Block N:.... Tax Lot N:
Name ,Pt1\ky a G
Street Addresses Box:1? 3 3 C/'` ("a+e r rra ce
City/Statc/Zip Code:Sdileit?r''e /"( 'W 3 s�
Office Phone:... Mobile Phone:...? 6— 14-g1?3
FaxN:....»...»..............».._..................
Grading Contractor Information:(if known at time of submitting tire t.ra.scon Control/'lun(or review)
Value of Grading Contract:S r( '1U'_/..Q° City of WS Contractor ID N:
Name of Grading Contractor:..xt:'.f.4.f!J..IIh/-6 NC license N: »»...,„........--
Contractor Contact Person::VII /V--1q Contact Phone: .3,6 314
Street Address/PO Box: 6 '?!! W IL ,ry Le »»..»»•
•
Citv/State/ZipCod« 5 f Gqfift'I e / // 1� S » » »..... ...�.«....,..�.»...' '.................:
Part B
Person(s)or firms w ho are financially responsible for this land-disturbing activity: (use blank page to list additional
person(s)or firms if needed))nn••••Contractors are not considered finarxialls responsible for property not under their ownerships"I
Name of Person or Fimt: *E!.Q'. 4. F It
Street Address/PO Box.
..�.6.? ......(0{1 ( )& '( "re(fate
City/StaterZip Code: Sfe'liC°awl e NL ¢ 3 5 5
Office Phone: Mobile Phone: 3, C 3/1 -693 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:
(usc 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 tt:._........,... _—
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
there be any change iinn the information provided herein,
Type or Print Name: ``�1`I 11" l e
Title or Authority: 9(e-.'5[ {°n7
Signature: `^"a Date: 3`r - 2-¢
•
1, a Notary Public of the County of e.1.11ffx.(.41
t State of .Q1FA/.L.CalQ.1W..1Ga...,do hereby certify that wi 1 w.1. appeared
personally before me this day,and being duly sworn,acknowledged that the above form was executed by him/her.Witness myl
hand and notarial seal,this.,,.. 1 day of .�1. »-.•..:0 014.
Notary Public Name: .L..) tZ .t.0,- .t1.��' NA PAYNE
NOTARY Ruguc
Notary Public Signature: „l�)L .L'r ‘(yL/`" GUILFORO COUNTY,NC
//1 ��.t.�Q�. �✓ ►arcotarwsbnErwu t0,27.2ob
My commission expires: f....... 'Votary. a