NCC241382_FRO Submitted_20240506

City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 2710I
111iislof•Silcm Mailing: PO Box 25II,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, I0,000
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: Jonestown Subdivison
Grading/Erosion Control Permit#: EN 23000133
Location of Land-disturbing Activity: 1068 Jonestown Road
Latitude: 36.0607800 Longitude: -80.3424716
Approximate Date that Land-disturbing Activity will Commence: 4-30-24
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ® Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 4.72 Acreage to be Disturbed: 1.68
Grading/Erosion Control Permit Fee: S ..$1800
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Email:Spiegel Email: [e-mail]
Office Phone: N/A Mobile Phone: [phone] Fax#: N/A
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN #. 6804-33-2882.00 Tax Block#: Tax Lot#:
Name: LGI Homes NC , LLC
Street Address/PO Box: 1450 Lake Robbins Drive , Suite 430
City/State/Zip Code: The Woodlands , Texas 77380
Office Phone: Mobile Phone: [phone] Fax#:
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: S 40,000 City of WS Contractor ID#:
Name of Grading Contractor: Bradford Siteworks , LLC NC License#: 86270
Contractor Contact Person: Chandler Bradford Contact Phone: [phone]
Street Address/PO Box: 219 Cassel Street
City/State/Zip Code: Winston Salem, North Carolina 27127

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: LGI homes NC , LLC
Street Address/PO Box: 1450 Lake Robbins Drive , Suite 430
City/State/Zip Code: The Woodlands , Texas 77380
Office Phone: N/A Mobile Phone: [phone] Fax#: N/A
If the financially responsible party is an out-of-state firm, provide information for the in-state registered agent:
Name of Registered Agent. LGI homes NC , LLC -- Josh Spiegel
Street Address/PO Box. 5511 Capital Center Drive , Suite 560
City/State/Zip Code: Raleigh , North Carolina 27606
Office Phone: N/A Mobile Phone: [phone] Fax#: N/A
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 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: Josh Spiegel ,VP of Land Development , LGI Homes
Title or Authority: Authorized Officer
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personally before me this day,and being duly sworn,acknowledged that the above form was executed by him/her. Witness my
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