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Home My WebLink AboutNCC216119_FRO Submitted_20211104STORMWATER/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 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 "N/A" in the blank space. PART A / Project Name: GiYiand v� 6w ass : Ergw&— �. ,Irro I Permit # S 1 S S 3 ---------------- --- - --- --------------------------------------------------------A ------------------------------------ Location of Land -Disturbing Activity: ................ -_---. Latitude _ . . _ _ Longitude Approximate Date to Commence Land -Disturbing Activity: _ _ _ _ _ _ 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: ....................... Permit Fee.�-------------------------------------- ............... Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name ----- (,!-l6A___ nsav{.' Y►-------------- E-mail address Gk �_ a---- k----- keM 1��_(oS:__SUZ Telephone ---------------------------•--- Cell #- Fax# ____---------------- ---------- Landowner of Record (use blank page to list additional owners): . C at( ----- �•-----� � 9eorti � L l-L-----_ �_01'!nrstName phony ik Name Owners phone # V- -UY- -I Q11------------------------------ Street Address/P.O. Box __1- i acav,_t--K�--- /_20 --------------- City/State/Zip Code Tax Block #: Tax Lot#: _.•., •..__•___.,___ - - - - -- -------------- --- - ----------------=---------------------- Street Address/P.O. Box -------------------- ------------------ City/State/Zip Code Zoning. ................ _ Zoning Approval: __-__-__ ----_•_- Contractor Information Required Prior to Permit Issuance North Carolina Stale Law requires hoot 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. S _ 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 kinder their ownership. llC Name of Pe son or Firm -pO---°x--- a44z� - - -..... Street Address/P.0. Box R t c----- 1_1 15 ---------- ty/StatN . p Code - Cietl4i,-iL(l' ?c1q-3 ----------------------------•------- Daytime Telephone # -------------------------------- --•--------------------------- Name of Person or Firm -.......... ---------- •--•............ ---------- •--------------- Street Address/P.O. Box --------•---•------------------•------------------------------- 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 the Registered Agent City/State/Zip Code --------------------------------------------------•---- -------•----epho -------------------.. ---- - Street Address/P.O. Box Daytime Telephone # 3-If the_6ttaiacially_respDl>Siltlrw.par1y is a partnership, give the name andaddEcauf each.GenffW_emWrrY c blank page to list additional partners). --- ..,,.---------------- -------------------------------------- Name of the General Partner ..........------- -- •----------•------------------------------ Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code Daytime Telephone # --------------------------------- - ---------------- Name of the General Partner --------------------------------- ------- ---------------------- Street Address/P.O. Box - ------- ------------------------ ------- ----....------....------ City/State/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 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.) 1 agree to provide corrected information shou[dere be any c r c in sh informatio provided herein. I 1 _ �dt *Gfv u- -- - ----. ._.__-------•-- V-tkw .off-----------................................. rnt Na e Title or Authority Sr Lure Date a Notary Public of the County of _-;JQh(lS�-------------------------------------, State of North Carolina, do hereby certify that 'Vlaa4%ftJL ------ 6j uo.&Ywt ---------------------------------------------- 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 ... _�_---__day of _ADq.US_ ............... 20 z Nlo arv�P-u6-hc ----',�,� El o11 -- - My commission expires: _ jQ_-S_ - --- -- '1 i.<------------ Z.- I% O T A RGcp !: wOwnkkt Eqim PUBLIC 0 -•,r��sN OOO,,*' �r/Ilil►�