NCC243504_FRO Submitted_20241113

wi(1 City of Winston-Salem Field Operations Department l Erosion Control Division
orrice: hell I . 1 era Street.Suite 328. Winston-S.11cm, N( 7101
MnskoSallik Mailing: PO Box 2511, Winston-Salem.N(• 7102
Financial Responsibility/Ownership Form
No person may initiate any land-distuthine ai tiv ity cmvedine N1.000 square feet for Family IN.�*Ilintd cnnctnuaic'n. 10.000
square feet for any other non-exempt pulp e.or part of a Urger common plat of development evice•ydint;rhe,e thrr hnht: h.zfsi this
form and an acceptable Erosion Control Plan have been submitted, re%icrosed,and approved by the City of Win<ton-`item Fr•',ion
Control Div ision and a Grading] nxton Control Permit has been issued. Please type or print Please place"N'A- in the I,t,mnr .tepee if
not applicable.
Part A
Project Name: ctonebriar Way Grading/Erosion Control Permit 1 :
Location of Land-disturbing Activity: 941 W. Clemmonsville Rd, Winston-Salem. NC 27127
Latitude: 36° 02'45" N Longitude: 80" 15' 10"''N
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 0 Other
Total Site Acreage: ....5.93 ac Acreage to be Disturbed: 6.10 ac...
GradinefErosion Control Permit Fee: $ ...1.652
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Joseph A.Thurmond
Email- mydreambuiltPgmail.com
Office Phone: [phone] Mobile Phone: ...[phone] Fax#-
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 6823-97-6839.... 6823-98-7243 Tax Block#: ....3853 Tax Lot#: ....027A... 027B..
Name- Dreambuilt Construction, Inc.
Street Address/PO Box: 105 Seldom Farm Ln.
City/State/Zip Code: Advance, NC 27006
Office Phone: ..[phone] Mobile Phone. ...[phone] Fax#-
Grading Contractor Information: (f known al lime of submitting the Erosion Control Plan fine rt.view)
Value of Grading Contract: $ City of WS Contractor ID#:
Name of Grading Contractor: Plitcumeuiq CoA4.Y..V.f h.t NC License#: 1 51-(10
Contractor Contact Person: J d M ATta Contact Phone:33( G i q nco
Street Address/PO Box: 10.5 ktetwyi. I:Y.1!\.' I(l
City/State/Zip Code: fr-VAN1 2100
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Part B
Person(s) or firms Rho are finaneiall rv' 'ontit►le for Ihit hod tthfttrbinc tltltl iff;; (It 0 1'1111k r 1." (II li:t utrittlr n.lt
person(s)or (li-nit it-needed).a'( OnIf Al fief.^.re hr.,t t+::::-(•!ed I:':'I.4..1 , ri`•1•i'l1 !kik' Pry'(•fi► It) li.'t rlrtit.r ltteir Irmtwr.hlp•64.
Name of Person or I irm _ .Q( pirib_ iIt,Construc.t!on,..1m. ,Joseph A Thurrtluntl .
Stint Adder« N)r>l1►k ..... 105 Sckioin f arm Lt1, . . .. .. . ... . .... ... .. ... . . .
c it.;`tatc /ip code: . . ...... n�dval)ce,_N.0.2700f0
0Ricc hhonc: .... (33b) 969-0460 \1obilc i'h+'p.. 1,_3_ 6 _345`2041 leaf b .
lithe financially responsible party is an ont-of-stale firm,pimvide Information for the ha,tntr rt-aaror'•l fr,t•nt:
Name of Re_igcred Agent•
Street 'lddre' TX')itos•
Cit1 'State Zip Code:
Office Phone: Mobile Phone: Fax #:
lithe financially responsible party is a partnership, provide information for each General Partner:
Name of Registered Agent.
Street Address'T'O Boy
Cir '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 Corm
must be signed by the financially responsible person, if an individual,or their attorney-in-fact,or if not an individual, by an ott;cer.
director.partner,or registered agent with authority to execute instruments for the financially responsible person.)I agree to pro,.
corrected information should there be any change in the information provided herein.
Type or Print Name: (--#412 k/:1A k
Title or Authority: L11-
Signature: C.244414%---At41Date: A-7/ 7'4
1, (jC' �11 e ' , a Notary Public of the County of A-C ,
State of...►L.J.00 )...CAN\'tic\ , do hereby certify that ChaVOlyk\ kTAt.t,wmtviel
appeared personally before me this day,and being duly sworn, acknowledged that the above form %%as executed by hjnvhter.
Witness my hand and notarial seal,this °.I day of J 03 — 20 . l
``pttlI ttti����
Notary Public Name: At" gAen ````�```,�C .»-N At/, ��,�
Notary Public Signature: 1- NOTARY
( 1 PUBLIC
My commission expires: Q 1 L Z 0 ZS O
,;9L olaq. $•
,'i,1 C°i N'C4:0
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