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Home My WebLink AboutNCC221099_FRO Submitted_202203180 City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 IVIRMHUM Mailing: PO Box 2511, Winston-Salem, NC 27102 Finanzial-Re-sponsibility/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 "N/A" in the blank space if not applicable. Part A Project Nam Culvers- Union Cross Road -- — - - ----- --:.:................................................ e --...--::................................-....... .-.........-............................................................. Grading/Erosion Control Permit #:...... EN2200019 ................................................................................................................................................ Location of Land -disturbing Activity: .... 1780. Pecan Lane Winston Salem, NC ............................................................................................................................................... Latitude: ........ 36°04'42.6"N ..... Longitude: ............................................................................................................................................ Approxiinate Date that Land-disturbing_ActivibLwim Commence: 04/01/2022 Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Lot/Lots Total Site Acreage: ..... 2.09 acres ................................................. Grading/Erosion Control Permit Fee: S.................................. ❑ Residential Single-family Subdivision ❑ Other Acreage to be Disturbed: ....... 1.75 acres .................................................. ----IWsor-to contatr9muld-Eroslo-wControl-related issues arise during- land --disturbing a-etiviti Name:.... Rai Bhander........................................................ Email: ......gsb@nculvers,com............................................................................ .................. Office Phone:... 19, 710:1947........................ Mobile Phone:....919:710:1947.......................... Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) Parma Pl"—6874293169, 68742922514-6874282969-- Tax Bhck #.'— .................. ... #........................ Name: Boyles Treva H. .................................................................................................................................................................................................................... StreetAddress/PO Box: .... 1569 Union Cross Rd.............................................................................................................................................. City/State/Zip Code: ...... !anersvi.l.l.e..N...9..2..7..2..8..4.. ................................................................................................................................................ Office Phone: , N/A ... Mobile Phone: N/A ............................................... Fax #:................................................. Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) ----- ---- — — N/A Value of Grading Contract: S . N/A ........................................... City of WS Contractor ID#:.................................................................. N/A N/A Naiveof Grading Contractor: ............................................................................. NC License #: ............... N/A N/A Contractor Contact Person: .................................................................................. Contact Phone:............................................................... N/A StreetAddress/PO Box: ............................................................................. ...... I ........................................................................................ N/A _ 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) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm: Bhander's Holdings, LLC ....... ....................... ........................................................ StreetAddress/PO BOX: .....I S6Q Cinem.a.Drive... ................................................................................................................................ City/State/Zip Code: ......... Fuquay Varina,.NC.27526...................................................................................................................... Office Phone: 919-710-1947 Mobile Phone: 919-710-1947 ................................................................................................ Fax #:................................................. If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: NIA Nameof Registered Agent%.............................................................................................................................................. StTeet-A-da-s IP0-B—OX-- N./A�...... —.... ....... ,.............................................................................................................. --------- City/State/Zip Code: .N/A ..................................................................................................................................... N/A OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:................................................. If the financially responsible party is a partnership, provide information for each General Partner: __mouse blankpage tc lift additional partners if needed)_ NIA Nameof Registered Agent: ................................................................................................................................................................. ..... .......... N/A StreetAddress/PO Box: ...................................................................................................................................................................................... N/A City/State/Zip Code: ........................................................................................................................................................... N/A 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. Typeor Print Name:.....".. rb�.... .�.1.4 K.....qnde.i�..................................... .................................................. Title or Authority: Q� 2 — ''JJ O � G Signature: .............(.... .�1............................................................ Date:......... �... .. c ............ .nLIaGU.. . ` e�!:�! ............I....... , a Notary Public of the Co ty of... .'- ....�.... �'................. .. 1 State of ("%_ 4 .. �'1 ', do hereby certify that V .r ... '.!�.V��... .....1�-� ......... , appeared `��N personally before me this day, and being duly kgn, acknowledged that the above f �v t`c��,,by him/her. Witness my hand and notarial seal, this......................................................................... day of n ...T :.................... 20" ,oUBV CG A')v Notary Public Name:.. Y)I MaiLL'••�3_07: o Z�.. •�% `. '1 Notary Public Signature: ..... r......v...................... 1i�CO1%%0%\v�� o...G..-?.?:.. My commission expires: _-Notary-Seat��