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Home My WebLink AboutNCC215183_FRO Submitted_20210915STORMWATERIEROSION CONTROL. DIVISION 100 East First Street, Suite 328, Winston-Salem, NC 27101 Financial Res ponsibility/Ovunership Form Erosion Control Ordinance No person may initiate any land -disturbing activity exceeding 20,000 square feet for a single-family dwelling or 10,000 square feet for any other purpose, before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Erosion Control Section of the City of Winston-Salem/Forsyth County Inspections Division. Please type or print. If a question is not applicable, please place "NIA" in the blank space. PART A Project Name: __-Villas at --Jefferson Ridge-------------------------------------------------------Permit#-____'= �_!gDc�Q --- Location of Land -Disturbing Activity; Coravan Dr. (east of Jefferson Forest Ct. - across the street from the Duke Power Substation) --------------------------------------- Latitude 36007'06.3"N Longitude 80°19'46.7"W Approximate Date to Commence Land -Disturbing Activity: June, 2018 Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot 9 Residential Single Family Subdivision Total Site Acreage: _7.04-_ - Acreage to be Disturbed, 4_33- -__-_- Permit Fee: $1,450 -------------- --------------------------------------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Aden Stoltzfus PE SEI Engineering E-mailaddress _ aden@seiengineering.com ---------------------'--__--_-_------------ ------._-__.___--_---_-- (336) 904-0207 _Cell # __ (336)-908-1371 ____ . _ Fax # Telephone ---------------- -------------------------------- Landowner of Record (use blank page to list additional owners): Nova Jefferson, LLC (336) 749-1012 - ----- ---- ------------------- --- ------- ----------------- --------------------------------------------------------------- Name Uwners phone # Name Owners phone # 206 North Spruce Street, Suite 2A street AadrassiiP.®. Ito-------------------------- .....--------- Street Address -------- Box ------------- »___-_____----------------- Winston-Salem, NC 27101 ________________________ ____________________ --------------------------------------------------------------- CitylState/Zip Cade PIN 8: 6806-74-3779Ap $c City/State/Zip Code 6806-75-5196.00 Approved by City Tax Black #:------------------- Zoning: RS=. ____-__-__-_ Zoning Approval: of Winston-Salem Contractor Information Required Prior to Permit Issuance North Carolina State Law requires that contractors he licensed to perform work valued at $30,000 and higher. A11 contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. $ 110,618.00 Value of Grading Contract To Be Determined Name of Primary Applicant (Grading Contractor) Street Address/P.O. Box City of W-S Contractor's ID # Contractor's N. C. License Number Contact Person for Contractor City/State/Zip Code Contact Person's Daytime Phone Number PART B 1. Person(s) or firms who are financially responsible for this land -disturbing activity (use blank page to list additional persons or firms). Contractors are not considered financially responsible for property not under their ownership. Nova Jefferson, LLC Name of Person or-Firm------------------__-_-----------__- 206 N. Spruce Street, Suite 2A Street AddresslP.O. Box---------------------�-"-_-__-- Winston-Safem NC 27101 --------------------------------------------------------- --- CitylSta#e/dip Code (336) 749-1012 ------------• Daytime Telephone #- -------------------------- ------------------------------------ Name of Person or Firm Street Address/F.O.-fiox------"__________ __ _______________ ----------------------------------------------------- City/State/Zip Code ----------------------- -------------. Daytime Telephone # 2. if the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. Name of theTRegistered-Agent------------------------------ Street Address/P.O. Sox» ------------ -------------------- ------------------------------------------ City/State/Zip Code Daytime Telephone #----------------- ------------------------- ---- 3 _Iirllle_t �i�tUy.r 5pD11SihJ p y is a partnership, give the name and egs e h �t�At{T�l parirlc,[. me blank page to list additional partners). --------------------------- Name of the General ]Partner Street Address/F.O. Sox- ---------------------------------- City/State/dip Code ----------------------- ------ ----------- Daytime Telephone #-_------_.... ------------ -------------------------------------------------- Name of the General Partner --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- CitylState/Zip Code ------------------------------------- Daytime Telephone # 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 i cially responsible person if an individual or his attorney -in -fact or if not an individual by an officer, director, partner or registered age fth authority to execute instruments for the financially responsible person.) I agree to provide corrected information should Cher t hange in the information provided herein. -- Andy f] eyfManager Type or rinte-----------------------------------------Title -r -thority----_------- ___--__------ -_ -----____-- Signature ---------------------------------------- -��1.� ------------------------------------------------ Da e it , a Notary Public of the County of - C p - -- - ---- -------.-_- __----- State of North Carolina, do hereby certify that A,y-�5------ appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this --77`` day of �- -__��--1-1 Y ---- ------ 20 [ --- - - - - ---- --------- ----------------- My Public My commission expires: ------- 'Z Z Margaret N Sisk Yoder NOTARY PUBLIC Guilford County, NO My Commission Explres Zt zoo