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Home My WebLink AboutNCC220719_FRO Submitted_20220210City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 9A111MSM Mailing: PO Box 2511, Winston-Salem, NC 27102 zu t 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 Permit has been issued. Please type or print. Please place "NIA" in the blank space if not applicable. Part A / f .. r. ..... L.. .�.....,1.. .........i...➢:.Ar.. $. [:.A..... 6.. .. O 6,, L� ` C, 1i Project Name:.... : ....... .... ...... Grading/Erosion Control Permit #• 4 f J ii- , ..I. ��.:� �..................................... ................................................................................. �7 �� Locationof Land -disturbing Activity:....3.4.. ...y. ............................................................................................................ Latitude: ......................................................................................... Longitude:............................................................................................ Approximate Date that Land -disturbing Activity will Commence: ............................................................................................................ Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision residential Single-family Lot/Lots ❑ Other 47! TotalSite Acreage:....:,. ........ :.................................... Acreage to be Disturbed: .................. d............................................... Grading/Erosion Control Permit Fee: $ Person to contact should Erosion Contro related issues arise during land -disturbing activities: Name:.1.�..4...�.....;`�i:....: ..C........... Email:...' :... °.. ....................... !t......1....�.... Office Phone :................................. ........ Mobile Phone::.r..... 7....t....r Fax #' Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN # :........................................ ..............„. Tax Block # ............. T Lot #:... ...... Name: r..�i E.'.... ��1 G'' c �', a —� : �.Y� �,` �:.'.:..�....� v....i�. `....... ... ..,....... .. ... ............................................ Y •frr..... ` :••r� b"i b"� r1 / �[ . Street Address/PO Box:.... ................................................................................................................................................ City/State/Zip Code: ...... ... ........ ...............................................A............................................................................................ OfficePhone: ......... r,'.`j1...1........................... Mobile Phone:.........., :9.............,..,.... ....................... Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $.:........................................ City of WS Contractor ID#:.................................................................. Name of Grading Contractor:. .�::::....�'�°.::`..... ...... �:::' .:.... NC License#:...I.....?................................................ Contractor Contact Person: I / ... ....t..°1.t....... ..... ?....f'2.::r . Contact Phone: .J....�. �.. X..�..... ........................... StreetAddress/PO Box: ........... ...................................................................................................................................................... City/State/Zip Code:........................................................................................................................................................................................... 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)** j*Contractors are not considered financially responsible for property not under their ownership* * * Name of Person or Firm:....: 15 .:5.. y.. .. :. d .Y` ........ .- C Ji �J ...... w\................................. StreetAddress/PO Box:... ... .....:..:...................................................................... City/State/Zip Code: ...... L.V... ... ...... J ... ......... - .......... 2..a 5...................00........................ OfficePhone:.... �6iMax :....................................................,.......oeone:......... .. ::..F If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: ........ ........................................................................................ Street Address/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.) C agree to provide corrected information should there be any t7ce's n the information rovid7derein. r.ff j1 �� Typeor Print Name:.. /1.; G ! �.�..............�m.�. yr.J.....�?...........................................................,....................... Title or Authority:....��:. 5/ �!„1?,�.. ........................................................................................ �... Signature:....... c ..., ........................................,....... ^ �........ / ...... g .......1!i... .... Date �.. I . ............. ... ...,.....,..................,..................... , a Notary Public of the County of%&�......................... State ot��:.: .. do hereby certify that .. h� l p ` �!! d4.,.. ,appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my nck handand notarial seal, this...?................................................................. day of .YJ. .T� ............................... , 20 ....... .. �I1 , Notary Public Name: . ..Y.V aN ......V k:1. Y............ Notary Public Signature: ."U. '.S/......... My commission expires: ...�1�,1............ BRITTANY HESTER Notary Public Forsyth Co., North Carolina My commission Expires Dec. 28, 2025 Notaf y Seal