NCC242479_FRO Submitted_20240816

City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101
WIILSN nlialrm 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: 240353.000 Pine Log CO. Erosion Control
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 8645 66th HWY, Rural Hall, NC 27045
Latitude: 36.247483 Longitude'
-80.301860
Approximate Date that Land-disturbing Activity will Commence: Summer 2024 - End of 2024
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
ElResidential Single-family Lot/Lots 4 1 Other
Total Site Acreage: t8.58 AC Acreage to he Disturbed: 7.92 AC
Grading/Erosion Control Permit Fee: $ 2,056
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Randy D. Miller !' Email: [e-mail] ,( r�
Office Phone: .. / �`s ���"Mobile Phone: [phone] Fax#: 31( ~ qy�' ,5V
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 6911-61-4687.000&6911-62-4091.000 Tax Block#: Tax Lot#:
Name: Pine Log Co., Inc.
Street Address/PO Box: PO Box 858
City/State/Zip Code: Elkin, NC 28621
Office Phone: j/6*'�R ��j! U Mobile Phone: [phone] Fax#: `fiv-1/ ..e'"P
Grading Contractor Information: (if known at lime of submitting the Erosion Control Plan for review)
Value of Grading Contract: $ City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/PO Box:
City/State/Zip Code:

Part B
Person(s) or firms who are financially responsible for this land-disturbi 1 . activity: (use blank page to list additional
person(s)or firms if needed) ***Contractors are not considered financially'respo ible for property not under their ownership***
Pine Log Co., Inc.
Name of Person or Firm:
Street Address/PO Box:
PO Box 858
City/State/Zip Code: Elkin, NC 28621
Office Phone: Mobile Phone: J �/
I.��J6U`- ��� 336-957-06 '2 Fax#: -- 4 �(,!�_-?7, c
if the financially responsible party is an out-of-state firm,provide info oration for the in-state registered agent:
Name of Registered Agent- .
Street Address/PO Box•
City/State/Zip Code: I
Office Phone: Mobile Phone: Fax#:
If the financially responsible party is a partnership,provide informati in 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 belie and was provided by me under oath. (This form
must be signed by the financially responsible person,if an individual,or their att•they-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 he yin.
Randy D. Miller
Type or Print Name:
Title or Authority:
President
----"V (""Date:
i �7
Signature: /7/
- .�
1 l!� , i . • i _i , `� L- a Notary, Pu is of the County of....:..'
State of....Ka' ‘ do hereby certify that . \ `.,' `-1•••••'i' l 1 r I appeared
personally before me this day, and being duly sworn,acknowledged thajt the above form was executed by him/her. Witness my
hand and notarial seal,this
,� ANGEL�t C. ,RSON MATT
Notary Public Name: n�`�\C`' C c a 4`
t Notary Pul,i;c,North Carolina
..(. �� �� � ��' Wiikas County
Notary Public Signature: 04,...
J \, My Cr,rrrmission Eupires
r IJla(ch 'i 9 2027 •
My commission expires: �`�-.0-1-k. 1 ' . .J Notary Seal