NCC242686_FRO Submitted_20240918

City of Winston-Salem Field Operations Department Erosion Control Division
Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101
Wlnstoll•Salrlll 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:
Fletcher Residence - 8001 McGee Road
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 8001 McGee Road, Rural Hall, NC 27045
Latitude: 36.2397 Longitude: -80.2628
Approximate Date that Land-disturbing Activity will Commence: August 2024
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ® Other
Total Site Acreage: 23.51 +1- Acreage to be Disturbed: 3.31
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Chris Fletcher Email: [e-mail]
Office Phone: Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Previous PIN#6920-79-5691.000; 5031
Parcel PIN#• New PIN#6920-78-4937.000 Tax Block#: Tax Lot#:
Name: Perimeter Point Properties, LLC
Street Address/PO Box: 4960 Indiana Avenue
City/State/Zip Code: Winston-Salem, NC 27106
Office Phone: [phone] Mobile Phone: [phone] Fax#:
Grading Contractor Information: (if known at time 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-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: Perimeter Point Properties, LLC
Street Address/PO Box: 4960 Indiana Avenue
City/State/Zip Code: Winston-Salem, NC 27106
Office Phone: [phone] Mobile Phone: [phone] Fax#:
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 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: Christopher "Chris" D. Fletcher
Title or Authorit . Mana9i Member
1 Z ozy
I, LAuei b A '&MJE1 , a Notary Public of the County of F 1l:Rs ,
State of Nan dRowiWA , do hereby certify that Chri6itfivr.D...Fle!- neC' , appeared
personally before me this day,and being duly sworn, acknowledged that the above form was executed by him/her. Witness my
5 'may al_hand and notarial seal,this day of ITILA.St......ir:::,.w„ , 20
. (� J;•�0TAR�FAQ,
Notary Public Name: ..La f.l.t.. .� .... .......
Notary Public Signature: .�LJf�l.4!� ....a , N '
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AVBLIG 'V My commission expires: NOV a2•D NoNa; , 041,„.••