NCC242649_FRO Submitted_20240828

6.1 City of Winston-Salem Field Operations Department Erosion Control Division
Office: 100 E. First Street,Suite 328.Winston-Salem, NC 27101
lkiialiul&trlii Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial Responsibility/Ownership Form
No person ma) 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: Rocklane Drive
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 0 Rocklane Drive (1 lot west of 4447 Rocklane Drive)
Latitude: ....m15.9293 Longitude: -8.0..1.5.5553
Approximate Date that Land-disturbing Activity will Commence: July 2024
Purpose of Grading:
❑ Commercial 0 Residential Multi-family ® Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots 0 Other
Total Site Acreage: 1.956 acres Acreage to be Disturbed: 1.9 acres
Grading/Erosion Control Permit Fee: s 844.00
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Luke Ward Email: [e-mail]
Office Phone: Mobile Phone: [phone] Fax
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN • 6857-89-8095 Tax Block#: 3243 Tax Lot#: 002
Name: Ferguson Development LLC
Street Address%PO Box: 751 W. 4th Street, Suite 110
City/State/Zip Code: Winston-Salem, NC 27101
Office Phone: Mobile Phone: [phone] Fax 4-
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: S City of WS Contractor 1D#:
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-disturbing activity: (use blank page to list additional
persons)or firms if needed) ***Contractors arc not considered financially responsible for property not under their ownership***
Name of Person or Firm: Ferguson Development LLC
Street Address/PO Box: 751 W. 4th Street, Suite 110
City/State/Zip Code: Winston-Salem, NC 27101
Office Phone: Mobile Phone: [phone] Fax#:
If the financially responsible party is an out-of-state firm. prop ide 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: Luke Ferguson Ward
Title or Authority: Registered Agent
Signature: % ',r°�'� Date: 0 6 / i g/ z o z_
I, ...ShR,tri a Notary Public of the County of �v\d56n
State of JqRr+ l CAM 11 htis- ,do hereby certify that Lu\ye Y\ amt., appeared
personally before me this day.and being duly ss'worn,acknowledged that the above for vas executed by him/her. Witness my
hand and notarial seal,this I 4-141
day of 20 R.(1.
SHERRI DOOLEY
Notary Public Name: .. k� t -b6O1l1 Q Notary Public, North Carolina
Davidson County
,�, t / e•(_1�� My Commission Expires
Notary Public Signature: ... tl(��'�` ^'`TJ) January 13,2027
My commission expires: 1 '3 1 a o a 7 Notary Seal