NCC243152_FRO Submitted_20241011

City of Winston-Salem Field Operations Department j Erosion Control Division
Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101
1Y111SIOWSIIPIIt Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial RS i ilit rs ! 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:
goal b.eyrti. m as, to s f,, •
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: A 0 g •�� . = -Se. 71 Q1t).
Latitude: 4 \v I< Longitude: — •'e ' a
Approximate Date that Land-disturbing Activity will Commence: C—ca) 4 21)
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
E Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 6 9 Acreage to be Disturbed:
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
�: e Name: .. .. t+.�, /�, �' VeW Email: .. . .......`. ... �(�,:: , h ba.. . e. /1(\
Office Phone:'„t:.,1to.4� 5` 1' Mobile Phone: 0` .11.1t?. `D Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#' ..ce us 1 AC Tax Block#: ( 1(-P Tax Lot#:.. ee aWCte'6 Name •
Street Address/PO Box:.. 14\1 \ 1 e `\
il
City/State/Zip Code:�,\,1,\M _ Q. A-1103
Office Phone: 5:1* t I. Mobile Phone: Fax#:
Grading Contractor Information: (f known at tune 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:

Brookberry Farm Phase 10- Isenhour Homes LLC
Parcel Pin Lot
5895-19-9648 1013
5895-19-9744 1014
5895-19-9804 1015
5895-19-9853 1016
5895-29-0823 1017
5895-29-1823 1018
5895-29-0797 1019
5895-29-0762 1020
5895-29-0646 1021
5895-29-0610 1022
5895-29-2611 1038
5895-29-1929 1043
5896-20-0060 1044
5896-20-0010 1045
5896-10-9061 1046
5896-10-9001 1047

Part
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: .... rx x .a. �� ' S
Street Address/PO Box: ....
fit\ \k'• \t) ` nV
.. .
City/State/Zip Code: .. IA..; . \ �� Z710
3
(P � � 11 l` A. Fax#.
Office Phone• ..... .'.C..... Mobile Phon
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:
1
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:ry..N \.: 1
Title or Au +.o rit °. L
Si nature / / Date: //� "7
g
I .1 4 ,, ,a Notary Public of the County of ‘)- r
State of a' ,do hereby certify that
VV..)A `,,, 1 , 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 'CA day of $.... ,20 . ....
"�_ MICHELLE MIZE
Notary Public Name:
1 tiV��" W NOTARY PUBLIC "
Forsyth County
Notary Public Signature: ... North Carolina
My Commission Expires March 7,2029
My commission expires: Ak...., 77..,•• Q Notary Seal