NCC241036_FRO Submitted_20240430

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) ***Contractors are not considered financially responsible for property not under their ownership***
Name of Person or Firm: tiJ ' 1 mj! HAW,vi Ca u�/ .,,
Street Address/PO Box: q/S/ t/`t Neer //vvii" 6k-lr i goad
City/State/Zip Code: /
Office Phone: Mobile Phone:(3 34) 1 —277' 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#:
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 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 in the information provided herein.
Type or Print Name: • .1 i10Y j7 VON C-4 U 0/L--
Title or Authority: 0 WNE
Signature:
"4�!�A P f�ff��� (--)— Mate: / Jai
C LI cL
I Jfl1►e, S'�� ,a Notary Public of the County of.... ,
o (_ ` 1
State of. . 1 `a `�`.1••U do hereby certify that •'•� ril . ..C�. ..1..i.,appeared
personally before me this day,and being duly swooJrn acknowledged that the above formG �wa�s executed by him/her.Witness my
hand and notarial seal,this day of Ce--- ' 20
-:%4
Notary Public Name: •• uWosEr S�pR
Notary PuDlk-Worth Carolina
9ADYSAi
Notary Public Signature: ( At Comml slop GulifurExpd trosAuQ 23. 2028
•1•v�•
My commission expires: j....2.. •• of ti '

' 1 City of Winston-Salem Field Operations Department Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
1011SIoll all111 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 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 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: G RAe-b✓OD b -f11Am
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 0 FF mew 15 Roo _.
z
Latitude: .. ... 3 6 2$ / a.e? �� Longitude: — go �
Approximate Date that Land-disturbing Activity will Commence: T/V E f 8,ug/Q Y 2 O.'/
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family 12Ilesidential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
2 S, e 3 a Ere S Acrea a to be Disturbed: /8.67 ez .ram
Total Site Acreage: g
Grading/Erosion Control Permit Fee: $
Person to contacton should Erosion Control related issues arise during land-disturbing activities:iv
zt CAu�/,�r' �` Email: J ►YY1myCaue1�I/ 77 e.B� ,/. LO✓Y7
Name:........ .s.1dtyr�/ �t �//
Office Phone: Mobile Phone: (3 3 b) 1 e, —2 777 Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#' 4 7 32—95-3 Z Tax Block#: 54 .476) Tax Lot#:...,,�1.l�,�
Name: 1 ebES ,?A-VD/t/ eAND/LL—
Street Address/PO Box: 7/S t4J /1 e ��K't/rim gd',kJ / 1 O BOX yo6
City/State/Zip Code: - `r't' 1 N � 7/v 6 �CFR)ERSVnt ��a7�8S
Office Phone: Mobile Phone: ..1. .36) � '277cFax`#:
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract:$ ..,f(!Q ..1... City of WS Contractor ID#:
Name of Grading Contractor: . iG •..Las G.Rpike s.S.G:4111 ..1Akc License#: ....C,.1... 7.30.Q
�h .
Contractor Contact Person: ...11l1i.V:G.... /l .L Contact Phone: .e2 ^ :c23 357
nn
Street Address/PO Box: ....1..Q. I n�l,(� ':145 •••
City/State/Zip Code: W.aLost- CV N Cr 97 7195::01 .