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Home My WebLink AboutNCC216917_FRO Submitted_20220105City of Winston-Salem Field Operations Department I Erosion Control Division Office: 1001-. First Street, Suite 328, Winston-Salem, NC 27101 W01011•Sillflll Mailing: PO Box 2511, Winston-Salem, NC 27102 Financial Responsibility/Ownership Form No person may initiate any land -disturbing activity exceeding 20,000 square feet for Single -Family Dwelling construction, 10,000 square feet for any other non-exempt purpose, or part of a larger common plan of development exceeding these thresholds, before this form and an acceptable Erosion Control Plan have been submitted, reviewed, and approved by the City of Winston-Salem Erosion Control Division and a Grading/Erosion Control Pert -nit has been issued. Please type or print. Please place "NIA" in the blank space if not applicable. Part A Project Name: Zinfandel Street 1 ................and....Stable................Bend.............Lane.......................3-062................................................................................................... Grading/Erosion Control Permit #: .6...0...3.391 ................................... ....................................................................................................................... Location of Land -disturbing Activity:. §Z, Stable Bend Lane & 5829 Zinfandel Street Latitude:36:1170 .. Longitude: ............................................................... Approximate Date that Land -disturbing Activity will Commence: 10/04/2021 Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ® Residential Single-family Lot/Lots ❑ Other Total Site Acreage- .8:86..................................... ..... Acreage to be Disturbed: :$......................................................... Grading/Erosion Control Permit Fee: $ .a .............................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Name:.Danny Alexander Email: dannyalexander22 a�hotmail.com Office Phone: Mobile Phone: 336.399.7516 Fax #....................................... ......................................................................... Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #: 6896.64:0200 & 5896-64-0620 .. Tax BIoek 9:.6576A.......... ............................................ ......... Name: ,Meadowlark....Developers.......LLC.... ............................................................................................................................ Street Address/PO Box: 49fl5 S NC..HWY...150...... .......................................................................... ................. City/State/Zip Code:.! xington,t NC 27214 .......................................................................................... Tax Lot ........ Office Phone: NIA .......................................... Mobile Phone: 336.399.7516 . Fax #:.NIA ..................... Grading Contractor Information: (tf Icnown at tinge of submitting the Erosion Control Plan far review) Value of Grading Contract: $.8............................................... City of WS Contractor ID #:.NIA......................................................... Name of Grading Contractor:.NIA................................................................I... NC License #:.NIA...........................................I... Contractor Contact Person: MA ....................................................I....."............. Contact Phone:.NIA....... ............................................... StreetAddress/PO Box:.NIA............................................................................................................................................................................ City/State/Zip Code: .WA. ................................................................................................................................................................................. Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional person(s) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** ann Alexander Nameof Person or Fit7n:.D..........y....................................................................................................................................... Street Address/PO Box: 4905 S NC HWY 150 ................................................... City/State/Zip Code: l�eXinton. NC 27214 ........................................................................................................................ Office Phone:.N/A.............. ... Mobile Phone 336-399-7516 .......... Fax #: NIA ...................................................................................................................... If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: .................................................................................................................................................. StreetAddress/PO Box: .......................................................... ............................................................................................ City/State/Zip Code: ........................................................................................................................................................... OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:................................................. If the financially responsible party is a partnership, provide 'information for each General Partner: (use blank page to list additional partners if needed) Nameof Registered Agent: ................................................................................................................................................................................ StreetAddress/PO Box: ...................................................................................................................................................................................... City/State/Zip Code: ........................................................................................................................................................... OfficePhone: ................................................... 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 form must be signed by the financially responsible person, if an individual, or their 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 Print Name: .Danny Alexande.r ............................................................................................................................. Title or Authority Rresident Signature: .................... �.......................................... ................................................ ... Date:..... ................... ............................................... , a Notary Public of the County of... ....................................., State of .... W......................................... . do hereby certify that .. .1� . z }� l'�. ...... appeared personally before me this day, and breinng duly sworn, acknowledged that the above form was executed by him/her. Witness my hand and notarial seal, this .............. 4........................................................ Iday of ... n +�.7 ��........... , 20 .�J..1.. a�B E& ,j Notary Public Name:...... ...... 4 OTAI� Notary Public Signature:.. N Y O ��UBL1G M commission expires: ... Seal -�' far�ru��tti+�usu`