NCC241072_FRO Submitted_20240410

6
:" 1 . City of Winston-Salem/Forsyth County Inspections Division
II < 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: ti 6SQ. 1 !�.l 1,_...k �{ ».»»..»......... ............................ perm............... »..................................»...».»
)Location of Land-Disturbing Activity: 0 CPeA u 144 QtA A,01. a . W....»_....,.m
Latitude - Longitude
Approximate Date to Commence Land-Disturbing Activity: It. l-„l _.,.,,..»,» »„» »- , , ..
Purpose of Grading: 9 Commercial 9 Residential Multi-family
9 Other(No development proposed) 9 Residential Single Family lot
9 Residential Single Family Subdivision
Total Site Acreage: it(v Acreage to be Disturbed: t, 1 Permit Fee: olCk
Person to contact� should erosion and sediment control issues arise during land-disturbing activity:
c
Name 1,c1..N A WTI V" E-mail address .Q ?.y.1..(g.,e0[.f;1/4wok hisl/vu-s•I
Telephone Cell# 1 i 1'I $56-L Fax#
Landowner of Record(use blank page to list additional owners):
NametlitAAAMad OWLS LW! —
44 Owners phone# Name Owners phone#
��
rV V?., 404
Street Address/P.O.Box Street Address/P.O.Box
take l& N L...........tit U 1 w »......
City/State/74 Code City/State/Zip Code
Tax Block#: 37'" i Tax Lot#: if Zoning: Zoning Approval:
Contractor Information Required Prior to Permit Issuance
North Carolina Slate Law requires that contractors be licensed to perform work valued at S30,000 and higher.
All contractors must have a Ciry of Winston-Salem contractor's ID#,available at no cost through the City's Revenue Office.
s �l -
-
Value of Grading Contract City of W-S Contractor's ID#
6tl MAAni [a:1 vl/t' 3
Name of Primary Applicant(Grading Contractor) Contractgqr�N.C. License Number
P 6 J'LO, Ct.0 414 UUUI A Street Address/P.O.Box Contact PersoIIIP
ontractor
t, ' 106 (�11h. • 5-502
City,/State/ ip 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.
Name of Person or Firm Name of Person or Firm
Po V?► .) et D47,1
Street Address/P.O.Box Street Address/P.O.Box
� 1 vitelS
Ci /Stat Code »_.........._............ ..
ty p City/State/Zip Code
'M. cos` goov
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
ty p City/State/Zip Code
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 jierc be a char a in the information provided herein,
/ (uaG kf »__......... tA-414;" w.,..._...__._............
Type or P ' t Name Title or Autt
..9q
Signs re Date
a Notary Public of the County of virt,d n
State of North Carolina,do hereby certify that ....1..1 i y.1l'. 'b ©ll/a f,Ye hb j.-2
appeared 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 0,4 gx, 20 1 t
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My commission expires: t` — Zr . »„ ;o 1,01) T A R Y m
MY Cvnrnspon Excion
10-5-2025
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