NCC242373_FRO Submitted_20240813

`�I City of Winston-Salem Field Operations Department I Erosion Control Division
�J ()thee: 100 E. First Street,Suite 328,Winston-Salem,NC 27101
IiiisiimSiIIt'm \tailin PO Box 25 I I.Winston-Salem,NC 27102
Financial Responsibility/Ownership Form
No person ma) initiate acuR it) 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: Exprezit Erosion Control Plan
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 120 Linville Rd, Kernersville, NC 27284
Latitude:36.109862° Longitude: -80.163042°
Approximate Date that Land-disturbing Activity will Commence: Land disturbing already commenced. EC items will be
installed ASAP
Purpose of Grading:
x❑ Commercial 0 Residential Multi-fmily 0 Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑Other
Total Site Acreage: Two lots that total 12.31 acres Acreage to be Disturbed: 2.00 acres
Grading/Erosion Control Permit Fee: S
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Anjana Patel Email: [e-mail]
Office Phone: Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Two lots that total 12.31 acres 6856-60-4984
Parcel PIN u• Tax Block#: Tax Lot#:
Name:
Pranju, LLC 6856-60-3603
Street Address/PO Box: 3906 Stafford Run Ct
City/State/Zip('ode:High Point, NC 27265
804-721-4288 •
Office Phone: Mobile Phone: Fax #:
Grading Contractor Information: (i/known at lime#/'submitting the Erosion Control Plan for mvie►r)
Value of Grading Contract:S City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/I'O lIox:
City/State/Zip Code:

Part B
Person(s)or firms‘‘Ito are financially responsible for this land-disturbing activity: (use blank page to list additional
person(s)or firms if needed) ***Contractors arc not considered financially responsible for property not under their ownership***
Name of Person or Firm: Pranju, LLC
Street Address/PO Box: 3906 Stafford Run Ct
City/State/Zip Code: High Point, NC 27265
Office Phone: Mobile Phone: [phone] Fax #
It 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 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: ..., r. /. —9/../fj/..7•••.../49TG .
Title or Authority: /.9/.V/9.a
Signature: r �!_ Date: Q / Zs a K
1iRu 14 1( a Notary Public of the County al ..G 'U
State of L•1 do hereby certify that ... .5 't P4e1 ,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 s day . .•. 20 a.••.f••
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Notary Public Name: .
11 = DONNA MARIANI
NotaryPublic Si nature: .1... �� ( ..• Guilford County
g = My Commission Expires
My commission expires: — I A % c�tc ,c x �