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HomeMy WebLinkAboutNCC243081_FRO Submitted_20241009 A City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101 11iIislmiSldP01 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: 4672 Gallant Lane Grading/Erosion Control Permit#: Location of Land-disturbing Activity: 4672 Gallant Lane Latitude: 36.1438 Longitude: -80.1388 Approximate Date that Land-disturbing Activity will Commence: Fall 2024 Purpose of Grading: ❑ Commercial ❑ Residential Multi-family ❑Residential Single-family Subdivision ❑ x Residential Single-family Lot/Lots 0 Other Total Site Acreage: 3.00 acres Acreage to be Disturbed: 1.37 acres Grading/Erosion Control Permit Fee: $....1,688.00 Person to contact should Erosion Control related issues arise during land-disturbing activities: Name: Keith Slate Email: sherryPtkofnc.com Office Phone: .(336)399-8836 Mobile Phone: ..(336)399-8836 Fax#: Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN#:6867-42-1768 Tax Block#: not posted online Tax Lot #:.not posted online Name: Keith B.Slate&Sherry B.Slate Street Address/PO Box:....112 Edgehill Court City/State/Zip Code. Kernersville, NC 27284 Office Phone: ..(336) 529-9267 Mobile Phone: ..(336)978-9009 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: 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 fmancially responsible for property not under their ownership*** Name of Person or Firm: Keith B. Slate Street Address/PO Box: 112 Edgehill Court City/State/Zip Code: Kernersville,NC 27284 '• Office Phone: (336) 399-8836 Mobile Phone: (336) 399-8836 Fax#: lithe 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 fmancially 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: Keith B. Slate Title or Authority: .. wne Signatur Date: t�9'� ` -� At 1, re-e-Leis m 90 an rt—c. ,a Notary Public of the County of etc-((1.5(�4-41 State of...I\10 C'Cxra mac. , do hereby certify that...V?. ! S Cett , 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 day of S t cvl\P-e r , 20 2-14 Notary Public Name: BrY.✓t aro,. 5 rn Q✓E 1 gREIVDA S. McDANIEL • BLIC Notary Public Signature: 4 . S n'lam`-1--A''- M ROCK NOTARY COUNTY NORTH CA-OLwA My commission expires: 05 " o`1— v`Z-0 2. q,l My co _ton E O