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Home My WebLink AboutNCC221401_FRO Submitted_20220408PM City of Winston-Salem Field Operations Department I Erosion Control Division (J Office: 100 E, First Street, Suitc 328, Winslun-Salem, NC 27101 NMsmn• ft 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 Permit has been issued. Please type or print, Please place "N/A" in the blank space if not applicable. Part A ProjectName:.., Y��:.......... ......�................ r ....... J ................................................................ Grading/Frosion Control Permit #:............. 6 3 Z,71n................................................................................ ................... ......................... Locution of Lund -disturbing Activity: ................. G .... IJC C'�5..,An............................................................... Latitude: ....... t ...............7......................1............................ Longitude: ...r p,.3..1.''...I............................. ........................ Approximate Date that land -disturbing Activity will Comrnelwce:............. � r,,...................... ..................................... Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision 2" esidential Single-family Lot/Lots ❑ Other Total Site Acreage: ........ '.................... ......•........... Grading/Ermion Control Permit Fee: $.................................. Acreageto be Disturbed: ........&.................................................... Person to co tact shuuid 10-oainn C'outrol related issues arise during; land -disturbing activitirx: a UlTicc Phrn,c:P' d..,.,.. Mobile Phone: �'! 3 {=ax !1: Landowner of Record: (use blankpage to Iisi additional owners if needed) r� Parvol PIN 11:...- �4.,.... .....�e. Tius Block It:. GQ C_ Tax Lug �:...... %.. ............. Ncc,iwc:. ? ..... ....ff... 1.t....... .............. .....................................................................................I......I............. Street Addres;,/P() Box: ............ ....... t.. `z,?....... %l' ... A,&— U,y City/State/Zif, C:ude:......... !`f. ��... /V.C.+..........2-1 {, z �..........................................r......,...................,.......,...............,. p ......4...........:.:.. 12 Office Phone:.. {P � 3 � 01r. Fax #................ .................................... Mnbilc Phone:................... ...... ...... ............w.,............ Grading Contractor information: (if known at time of'subntitting the Erosion Control Plan,for review) Value of Grading Contract: $ ....a�A.. nd �,,,,,,,,,,,,,, City of WS Contractor TD#:.......,...,....,,,...............,,.,..,...,..............,...., Nameof Grading Contractor: ...... ... t`;...v .......................... NC License#:................................................................ Contractor Contact Person:..... Contact I'houe: .�.... 9zz- ,9��,o ..... . . StreetAddress/PO Box:.......... �'.....r..•....:✓..........................................................•....................,..... City/State/Zip Code :............. r4fsl...........2?o�t� -• �l 0 .......................... . ........... Part B Pvrsoti(s) or fit -Ills ►vha at* financially responsible for this land-disttrrbing aefivity: (rise l>lstnl( pa6i, I(, list additional iur.dod) �'t',Illr.0 fni .;u'r IisM volv"du.1cd IIinillici lily 1CSpOnSli].Ic fbi IProperty Ilot lituiv.l III it ownership*** Nam,. I,r 1•er--sill) III Fin.j I. rt]�.IJ,csfi., �•J'�.. �� .... •............................................ .. •.Y.......................................................................................,........_................ ................... orrice f'h❑}le:. �� r? :�� .. Mobile Phone; • ��...� �r �d-�� If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Name of Registered Agent:_... ......................... ......... .................... ...._... ....-_.................... ,,..................-... Street Address/PO Box: .................... .................................._.... ... City/State/Zip Code; ...... .............. — I... I ................ ........... . OfficePhone: ................................................. Mobile ... Phone: .................................................. Fax #:.....,.......,....,.......,,.,..,..,.,. ,....., If the financially responsible party is a partnership, provide information for each General Partner: (use biwil - page to list additional portners if needed) Name of Registered Agent-....... ... I., ....................... Street Address/PO box: ................ ............. City; State; Li'p Codc........................................................ .. _.......... .......................................... .................. Office Pholic:.................................................. Mobile Phone:... ..- - Fax #; T'h� ah:,��+ 1t7t1}Iillilli[}[7 !S twe tntd correct to the 13CSt of In-V 1;nrs�s Ie(i�.0 and Itirlic t',trt�i wt+, provided by IFIC llndw gate. (This forfzi most Ile sigilul by thr financial1), rcypo lsihlc jYcrstall, if:an 1ndlVl[1na1, {tl 1116 ;M0411L•y-I11-ti1(:t, of- iI'llor all IndiVidoni, by an officer. (fit-ccnsr. pnrilier, tw rcgisicred regent with suIfi lrily to execute ii1S1rL mc)II5 All the rinalwially respulisilzlr perse.m f Agree to provide wrrcet.ed i0ormation should there he any ch.utgC if1 rile iittormatioll provided lic:,riri1). ..1� Type or, m Print Nae: .......... ............._.... wi.,...............,.._........ �...............................................-...................... -.... Titre Oi Authoriiv:. �.-...._ ' .......... ....................................-................................... .. 51�n%itlll'C'r' -. r �f /........... .... ... Date.. ........ . E, ........,.: :.a...l..l.,•.?.:[,.L ' �. :r Nolin'y Public nl Ilie Count of �r'r` .4,. .y. , /r y........G.i..hr:.e..�...................... ct.'!'I' :.?f ..f..Y.rt.l,:l. !.1.. }:h.:.F.�.cJ.-�..4.. , do [iercby coriily flea[ ... 1 ,�_ I.. ...1,.}.� t�.� 1ti.................. ........... :111pCal'l.'(.i personally before me this day, and �being duly ,sworn, acknowledged that the above form was executed by hint/her. Witness illy hand and notarial seal this ............. ..`..�. .............................................. .... day of'..Y.�41!�:?�:................. as Notary Public Name:.......!,�....{'.:�..�;!.....!."�. SI r �� BIRTH MACEY NOTARY PLIEWC Dovla Counly ?Notary Public Signature: .. . ? �........ .,•J„. (, ,„ ' Nr1rIi7 C'nrrafina r• I My Gorllrnlsslon Fxplres April 28. 2023 ......... My commission expires: - ..:....s;�.15':.....'�.3....................... Xolury Sea!