NCC220250_FRO Submitted_20220114

STORMWATERIEROSION 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: OLD MILL- Permit#
Location of Land -Disturbing Activity: T" Arden Drive, Clemmons, NC
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Latitude 36,0180 Longitude -80,3692.
Approximate Date to Commence Land -Disturbing Activity: April 1, 2021
Purpose of Grading: F�Commerciai Residential Multi -family
Other (No development proposed) Residential Single Family lot
H Residential Single Family Subdivision
g 41.06 --- _ g Disturbed: Permit Fee:
Total Site Acreage: Acrea a to be Dist
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Todd Isenhour Name __--------------------------- E-mail address [e-mail]
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Telephone [phone]
---------------- Cell #----------------------------- Fax #---------------------------
Landowner of Record (use blank page to list additional owners):
Old Mill Subdivision, LLC [phone] Isenhour Homes, LLC [phone]
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Name Owners hone # Name Owners phone #
3411 Healy Drive, Ste A 3411 Healy Drive, Ste A
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Street Address/P.O. Box Street Address/P.O. Box
Winston-Salem, NC 27103 Winston-Salem, NC 27103
-------- --------------------- ------- --------------- ----- -------------------------------- -------------------------------
City/State/Zip Code City/State/Zip Code
Tax Block #: Tax Lot #: ----_---- Zoning RS9, RM5-S Zoning Approval:
- ---------------- ------ ---------------- -------------
PIN #'s: 5892-57-0376 (Portion ofl; 5892-57-7962 (Portion of)
Contractor Information Required Prior to Permit Issuance
North Carolina State Law requires that contractors be licensed to perform work valued at 530,000 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.
Old Mill Subdivision, LLC
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Name of Person or Firm
3411 Healy Drive, Ste A
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Street Address/P.O. Box
Winston-Salem, NC 27103
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CitylState/Zip Code
[phone]
Daytime Telephone #
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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.
- N------e ----___-----_ ._-------- -_.__ -. --------------------
ame oh--------e-dAenCitylState/Zip Code---- ---------------------------------------
Regis
rgt
- ----- ___---------- --------___--------------__----___ ---------------------------------------------------------------
Street Address/P.O. Box Daytime Telephone #
-Lf tii�it1D�L3UY_[espnit5ibpstrly is a partnership, give the name blank page to list additional
partners).
---------------- ----------------------------------------------
Name of the Ceneral Partner
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Street Address/P,O. Box
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City/State/Zip Code
--- -------------------------------
Daytime Telephone #
----------------- ---------------------------------------------
Name of the General Partner
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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.) l agree to provide corrected information
should there be any change in the ' ation provided herein. Manager
Old Mill S divisio _LLC _ _� odd Isenhour)
- .-_ --- ----- ---------------- -- -----------------------y------------------- --------- -----------
T pe or _- Ve
�borit
--------- - - -------- ----------
Sign re -
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__�0.41.__ 11�'nor�______________ , a Notary Public of the County of
State of North Carolina, do hereby certify that ��j 4 ___�r_- -
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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 _-_a p�.S ___day of __- 4�,___--------, zoa1 ttiyylllllrlul���//i
\`\`5JAON
- •%- - ---------------------- ------- - ------ s---- --
Notary P is a
My commission expires:
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