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Home My WebLink AboutNCC216772_FRO Submitted_20211208ST'ORMWATERIEROSION CONTROL DIVISION 100 Fast 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 "NIA" in the blank space. PART A Project Name: Clouds Harbor Subdivision-Phase1 Permit # 2---_. Kti -----------------------------------------------------t-----------------. _ Location of Land-DisturbingActivity: �� y _____ ____________ _ _ __ __ ___ _ __________________ _ __ ____________________ Latitude 36.019410 Longitude -80.363876 Approximate Date to Commence Land -Disturbing Activity: . Vd� €� ----------------------- -------------------------- ---- Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Sin le Family lot Residential Single Family Subdivision Total Site Acreage- -27.0 Acrea a to be Disturbed: 22.60 _ Permit Fee ----------------------------------------------------------------- _____ -- ---g_ ------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name-----------------�'?e--�h _1ve��___ E-mail address .. Telephone ------------------- ------------ Cell #tP_�1�;�Q7Q------ Fax #------------------------ Landowner of Record (use blank page to list additional owners): Clayton_l'roperties Group, inc Sdba Shugart Homes_____ Name - Owners phone # 221 Jonestown Rd ----------------------..--_------------------------------------- Street Address/P.O. 13ax Winston Salem, NC 27104 City/State/Zip Code Tax Block #: 1:4242, 2:4210, 3:4210 Tax Lot #: 1 001 _2:101,• 3:105 -------------------------------------------------------------- Name Owners phone# --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code Zoning: Proposed: RS-9 --_ Zoning Approval: Contractor Information Required Prior to Permit Issuance North Carolina State Low requires that contractors he licenser) to perform work valved 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. $ 200,000 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 Ill # 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. Clayton Properties Group, inc (dba Shugart Homes) --------------------------------------------------------------- Name of Person or, Firm 221 Jonestown Rd Street AddresslP.O. fox ---------------------------------- W€nston Salem, NC. 27104 -------------- ---------------------- - ----------------------- CitylStatel7.ip Code 336-765-9661 ------------ Daytime Telephone # ----------------------- Name of Person or Firn- --- ------------------------------------------ Street Address/1 Box -------------------------- City/State/Zip Code DaytimeTelephone#--�-�- 2. If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. -- the I:- --- Agent/Zip ---- ----------.--_---------------- C-y Code------ -.-------.------_-,------------------- Marne .. _ ---- --- -- ---_----_-_-_-_ _-_-_---_._--_ -_ Street Addre-ss/--P.O--.--Box------ ----------------------- Daytime Telephone# 3 .i£iileuGiaUY-resFo� I>y is a partnership, give the name blank page to list additional partners), -----------th------neral--..___..Par..tner_..---------------------------------- Narne of e Ge ---------------- ----------------------- ------------------------ Street Address/P.O. Box CitylSfafefZip Gade---------------------------------------- -- ------ Daytime Telephone # --------------------------------------------------------------- Name of the General Partner ---------- --------------------------------- ------------------- Street Address/P.O. Box ---------------- ------------------------------------------- City/State/Zip Code ------------------------------------ Daytime Telephone N 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. --------------- ------ ------ ---------------- ------------------------ Type or--t Nam—W --------------- Title or Authority -------- ----_-_----_---_--------.--------- Sign- iuer _— Date irQ_ --_-- , a Notary Public of the County of ___��?-.-----_ __-_-----____._ _____ _______________________- State of North Carolina, do hereby certify that it's-_a�g,-_---_----_ 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 ----- 7 `r" day of �U �20 � ....... ___ -- _ __.__.__._-��__ �- 1�tal ub1 ----------------------- My---- -. commission expires: ... o� JODIE S MELO NOTARY PUBLIC FORSYTH COUNTY STATE OF NORTH CAROLINA IMY COMMISSION EXPIRES 09-25-2022