NCC241613_FRO Submitted_20240528

UP City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
Winston•Salem 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 �7 ,j� I J
Project Name: 7 1 `�`74 -1 Ski �-K�� �C I� �V � Ivy �.
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity' ..5 q pfafv(+e..1 S4 rc., a tI C c2`7/o t
Latitude: ..31l• I f' 1 120 Longitude: x B Q - 30
IS I 0
Approximate Date that Land-disturbing Activity will Commence: 5 ' c 0- 0?®c`I
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
irk Residential Single-family Lot/Lots ❑Other
Total Site Acreage: 0 ' a Acreage to be Disturbed: 0 .
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: �d�� L-' a Email: e,X-a he_ci r `7 17 ineci I ; CQ m
Office Phone: NJ A Mobile Phone: 336- 5 ' `7l 7 5' Fax#:
Landowner of Record: (use blank page to list additional owners if needed) -�
Parcel PIN#' 5 `t'" ()La° Tax Block#: .?."5/ LR Tax Lot It. a
• 1
Name: .. U 1 e-c.s iS 4 /" fr y-tJ Q/J L
Street Address/PO Box:...S.Lee 3 N . i v �, H!V ir�d. 15-0
City/State/Zip Code: e rn o.j i` LJ
�...... C- S2 170 r0?
Office Phone: 3 6 Mobile Phone: At/ Fax#: Aj I If
Grading Contractor Information: (f known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: $ 0l..Qs... City of WS Contractor ID#:
Name of Grading Contractor: .3-a- 1, ff e- .6 ((Ad �q NC License#:
Contractor Contact PeronpOo/J (n��V` Contact Phone:
Street Address/PO Box: ,Bo)L
City/State/Zip Code: ....1..0..o.a.Q v i tic l..l 4 7o 3 D

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: (pr �, 1.�1 I derma yJ S `-" ��� ly t®k, LLC
Street Address/PO Box: 03 M ` 1J C Nut l 60
City/State/Zip??Code: �1 e-m�O ti� A 4 C d `7.Q/01
Office Phone:3.t(1-3 T3 - (05—
Mobile Phone:534 11c ` .Zcl Fax#: N in
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:
(use blank page to list additional) artners if needed) 1 f
Name of Registered Agent:... l l ob& E �a l.003
Street Address/PO Box:.W&O. ..... IL C'_ H .... 15�
City/State/Zip Code:..l.r(L..-1 o A � /Di /-
Office Phone: >l/L� Mobile Phone:3540-3 �'5-lQc. ........ Fax#: A//
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,pai tiler,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: ... S2ell k'1/ tt0kn'U
Title or Authority: ... emb.jL(...m-Un1L QC
Signature: ...1 4 rG 4024 Date: 5 La r Oa('
I ... .L....1`..1. � ). '. , NotaryCounty �,�i . U1I,aQf
... 9 ( la�� Public of the of
State of LQd h..0 .c..n.L.J.J2 4. ,do hereby certify that......t�.Q b,(2.i4 5 W ooiQ , 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 off 20 oat...
Nnriny
...
L RICE
Ia
Notary Public Name: AnQ {...... l C[((�_ ` �'�° et;�;•�O yS
P�(CI1d. - ',� and•
Notary Public Signature:`'i - ; NOTARY
PUBLIC V
v 21
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My commission expires: �.:.)O, c1 L
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