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Home My WebLink AboutNCC220457_FRO Submitted_20220124City of Winston-Salem/Forsyth County Inspections Division 3 100 E. First Street, Suite 328, Winston-Salem, NC 27101 INSPECT OHS 01VISION 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: Cliffdale Woods ........................Permit#.............................................. ......................... Location of Land -Disturbing Activity: .....0 Cliff..dale Drive.. Winston-Salem NC .............................................................................................................. . . Latitude :36 0g46 Longitude -80,3119 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: 14.60 Acreage to be Disturbed: 4.83 Permit Fee: Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name WIII Derrickson E-mail address wderrickson mUn O.COm...................................................................................@............9.................................. Telephone....33.6-23.1.-6.7.6.73357231-_67.6.7 ...... Cell #.... 336.-.97..9-4.0.54................. Fax # Landowner of Record (use blank page to list additional owners): Clay.ton..Properties..Gro.up..Inc.D.RA Mungo„Homes ..................... I....... ,... ,,,,,,,...,...,.,.....,...,.:....................................................... Name Owners phone # Name Owners phone # 221 Jonestown Road 336-231-6767 Street Address/P.... Box Street Address/P.O. Box Winston-Salem, NC 27104 .......................................................................................................................................... =----............................ --........,............................ ............... _ ........----... City/State/Zip Code City/State/Zip Code Tax Block #: ........... Tax Lot #:.................................... Zoning .................................... Zoning Approval: .......................... 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. $ 82093 Value of Grading Contract City of W-S Contractor's ID # 81396 Name of Primary Applicant (Grading Contractor) Contractor's N. C. License Number Will Derrickson Street Address/P.O. Box Contact Person for Contractor 336-979-4054 City/State/Zip Code Contact Person's Daytime Phone Number PART B 1. Person(s) or firm(s) 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.dtoo. /'nGirlgo PO Nip ........................ I ........................... Name of Person or Firm 221 Jonestown Rd ................................................... Street Address/P.O. Box Winston-Salem, NC 27104 ........................................ . City/State/Zip Code 336-765-9661 D....yti............ Te........le......o........ne ................. . ame ph # 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 naive and street address of the registered in -state agent. ..............................................................................................4..........,.................................... :................... ................................. :............. ..:............. ........................ Name of the Registered Agent City/State/Zip Code Street Address/P.O. Box Daytime Telephone # 3. If the financially responsible party is a partnership, give the name and..add.ress.o.f..eac.h..Genera..l..Partner.... (use blank page to list additional .................................................. partners). ........................................................................ Name of the General Partner Street Address/P.O. Box ........................................................................ City/State/Zip Code .D......ayti.......me...........le..............#... ...................... Te..phone # .............................................................. ........ ....,...,.......................... 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.) I agree to provide corrected information sho then: be any c an in the information provided herein. .�x� �........... . w............... ........ / a ►.a.. �....................... Typ or P iint Name Title or Authority ............ .................. ........................,....t.�..1� . 0?... .................................. Signature Date I, ..... a Notary Public of the Count of 'A .... ..................................... .............. n State of North Carolina, do hereby certify that Q.n �.!t.........AA.......... ...(....................................................: ....., 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 41 ..........1........ day of ....... , 20 „. ... .... .... ............... 1.....l...�..... Not ublic My commission expires: . .... IMy ANGEL G. HIATT'Notary Public - North Carolina Forsyth CoyplYq Commission Expires Z