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Home My WebLink AboutNCC215453_FRO Submitted_20210930STORMWATER/EROSION CONTROL DIVISION 100 East First Street, Suite 328, Winston-Salem, NC 27101 Financial Responsibility/Ownership Form Erosion Control Ordinance No person may initiate any land -disturbing activity exceeding 20,000 square fbet 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 "N/A" in the blank space. PART A Project Name: Longwood Village Permit# --------------------- -------------------------------------------------------------------------------------------- Location of Land -Disturbing Activity: 1138 Lewisville-Clemmons Road SR 1156), Lewisville, NC 27023 ___--_-___ Latitude 36.0817 Longitude-80,3933 Approximate Date to Commence Land -Disturbing Activity: June 15, 2021 ---------------------------- Purpose of Grading: Commercial Residential Multi -family Other (No development proposed) Residential Single Family lot Residential Single Family Subdivision Total Site Acreage: _13 95 _______________ Acreage to be Disturbed: Permit Fee: Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Ron Davis arpllc@aol.com --------------------------------------------- E-mail address _-1----------------- Telephone (336) 462-0705 (336) 462-0705 -------------------------------- Cell #----------------------------- Fax # -------------------------------- Landowner of Record (use blank page to list additional owners): Longwood Village, LLC (336) 462-0705 N ---am---e -------------------------------------O-wn----ers----phone # Post Office Box 609 ------------ --------- ---------__ _---------------------_-------- Street Address/P.O. Box Lewisville, North Carolina 27023 --------------_____ -------------------------------------------- City/State/Zip Code --------------------------------------------------------------- Name Owners phone # --------------------------- ----------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code Tax Block #: 4433 Tax Lot #: Zoning: _RS _9--_-_------. Zoning Approval: __________________. PIN #5885-1^6-$9_2 (portion of) and 58-85-$'f-1348 Contractor Information Required Prior to Permit Issuance North Carolina State Law requires that contractors be licensed to perform work valued at $30,000 and higher. All contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. Value of Grading Contract Name of Primary Applicant (Grading Contractor) Street Address/P.O. Box City/State/Zip Code City of W-S Contractor's ID # Contractor's N. C. License Number Contact Person for Contractor Contact Person's Daytime Phone Number PART B 1. Person(s) or firms who are financially responsible for this land -disturbing activity (use blank page to list additional persons or firms) Contractors are not considered financially responsible for property not under their ownership. Longwood Village, LLC (Ron Davis) Dame of Person or Firm - - ----------------- Name of Person or Firm Post Office Box 609 -----------------------------------------------------_. Street AddresslP.O. Box _.__._---.---------------------------------- - --------------- -------- Street Address/P.O. Box Lewisville, North Carolina 27023 ------------------------------------------------------------- City/State/Zip Code ---— -------------------------------------------------------- City/State/ZipCode (336) 462-0705 ------------------------------------ Daytime Telephone # ------ ._-._-__-_------------__--_--_. Daytime Telephone # 2. If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. ----------------------------- ---------------------------------- Name of the Registered Agent --------------------------------------------------------------- City/State/Zip Code - - ------------------------------------------------ Street Address/P.O. B-ox --------------------------------------------------------------- -- Daytime Telephone # 1117$u�i3Uy_rti5pstnihl�p�tly is a partnership, give the name and. blank page to list additional partners), --------------------------------------------------------------- Name of the General Partner ------.----------------------------___. _------------_-------- Name o€ the General Partner --------------------------------------------------------------- Street Address/P.O. Box -------- -------------------------------...---------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code --------------------------------------------------------------- City/State/zip Code ----aytime------Telep--------one -----# ------------- D h Da Y time Tele p hone # 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 his 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. Manager Lan wood Village1 LLC_fRon --- Davis______________________________________________________________ ---------------------- T a ame Title or Authority ---- ---- -- - - =� �...------------------------------- _51-2p ai!-----___ - ----------__ _______.----------_ SiOUte 1 _K_ aij._1J, _][ Viz - a Notary Public of the County of State of North Carolina, do hereby certify that _____--- 0-a-_____________________________________________________________ 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 _ �Q _day of _ -_-__- 20 dl _ `\N\\\` soy rJJiVi��`�/fi My commission expires: - -- -1---- a-- ------- ---. Notary Pu 1 A--- ------------ J J— /'%��fl