NCC242937_FRO Submitted_20240924

will City of Winston-Salem Field Operations Department I Erosion Control
Division
IhiishoSalm Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
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: Somerset Heights
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 801 Somerset Drive
Latitude: 36.0477 Longitude: -80.3341
Approximate Date that Land-disturbing Activity will Commence: Fall 2024
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family © Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots 0 Other
Total Site Acreage: 87.64 acres Acreage to be Disturbed: 52.01 acres
Grading/Erosion Control Permit Fee: $ 8,040.00
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: .....Dixon Pitt Email:
[e-mail]
Office Phone: .[phone] Mobile Phone: ..[phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#:6803-48-8148,6813-47-3375,6803-38-5166 Tax Block#: .3900,3988 .... Tax Lot #:..011,075
Name: Williams Land Development, Inc.
Street Address/PO Box:....331 High Street
City/State/Zip Code• Winston-Salem, NC 27101
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:$ TBD City of WS Contractor ID#:
Name of Grading Contractor: Thomas Stanley Grading & Hauling.... NC License#: 59544

Contractor Contact Person: Bob Westall Contact Phone: [phone]
Street Address/PO Box: 1278 NC-68
City/State/Zip Code: Stokesdale, NC 27357

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: Williams Land Development,Inc
Street Address/PO Box: 331 High Sreet
City/State/Zip Code: Winston-Salem,NC 27101
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: Stephen T. Williams, Jr.
Title or Authority: President
Signature: 7---- (// 40"... r. Date: ?MAY
Ly
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I, bk ker-1 ?. , a Notary Public of the County of FR i h
State of /Uo.r.BA 6.41761" , do hereby certify that 64e.p 77 `(Ica te$ J r , appeared
personally before me this day, and being duly sworn,acknowledged that the above foi tit was executed by him/her.Witness my
hand and notarial seal,this l A day of 6epie " , 20 Z`/
Notary Public Name: NOTARY PUBLIC
FORSYTH COUNTY, NC
•Notary Public Signature: 47:7
My commission exp,res .21/41/Aes
My commission expires: 2 14.1 A Notary Seal