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Home My WebLink AboutNCC221851_FRO Submitted_20220518City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 Llriuslon-Salein Mailing: PO Box 2511, Winston-Salem, NC 27102 Financial Responsibility/Ownership Form No person may initiate any laud -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 qq Project Name: /t Grading/Erosion Control Permit #: Location of Land-disturbingActivity: Z� 9� �'� �� ' ` `^ �" 1.J u .S %�' ty..............................................................::"`-.......................................... .............�................. Latitude U !�t7 Longitude: Z� .................................................................................................................+-.............................................. Approximate Date that Land -disturbing Activity will Commence:........ •.27. .................................................................................. Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision Residential Single-family Lot/Lots ❑ Other Total Site Acreage:..... �: �.i7.................................... Acreage to be Disturbed:........:.................................................... Grading/Erosion Control Permit Fee: $ ....."I.:.c�...... Person to contact should Erosion Control related issues arise during land -disturbing activities: Name:.N�;S�;r�-.— • '(Las � ��1Gz5Jt,,5�3 �:^•. ............................................................ Emaul:............... r.l i.l��.....................,............ �:...................................... / ..... G..`�!`:.7-:. �- 3........ Fax #:.......1�/.. A Office Phone: is' �F .� ............................................. Mobile Phone: ...................................... Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN#:.................................................................................. Tax Block #:... ..:Z .�J.6........... Tax Lot #:... C<<% ................ Name:.�� `L'' Street Address/PO Box: ..�J��.....................................`��1'—'`?'....wQ .......................................................................................................... City/State/Zip Code:.....�'��!' ` 5�...... �''T.....'�� F06, ............ ..........................f...................................................................................................... Office Phone:. �a� ...................................8... Mobile Phone: ......... �.(..�':............................... Fax #:....... 4l ............................. Grading Contractor Information: (f known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $ ....�'. �� ................... City of WS Contractor ID #: ........ ??.......................................... r................. . Name of Grading Contractor:. `�� !'s' , C" v 1G� f .................. NC License #:....... rkb.2:.)_�........................ ► "'�,-S Contractor Contact Person: ................................. Contact Phone: ................................... ��Z 2 Street Address/PO Box: .... .Z7a2Q.... �7.>e?�J ,- ':... P..z\ r..--E'!?.:c....................................................................................... City/State/Zip Code:..... .2....��. ....................................e............................................................................................................ 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:....t�,l'!�? t. ... (`-6 A ....................................................................................................... Street Address/PO Box: ..��....... . .. ' 3 �>�.... Lv fi ...................................................................................... City/State/Zip Code: ....... ..l...�� Office Phone:.. 7 � ....... ......6 - �� ?�'.... Mobile Phone: ..........."f .L' .............................. Fax #:.....! ! '............................. ............ If the financially responsible partyisan out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: ...... !4.1A......................................................................................................................... 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 attomey-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. Type or Print Name: ..... .. ....................... A ............................................................................................................................. Title or Authority:......`` .................................................................................................................................... Signature:....................................................... Date:.... �/�� 2 — I, ........Jo...Ann Vermeulen........................................................ . a Notary Public of the County of...Forsyth..............................., State of.. Carolina , do hereby certify that .......David„ .................eappeared ...... ........... personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my hand and notarial seal, this.....................................................19th............ day of ...... APr.il............................................... , 20 ..��.... Notary Public Name: Jo Ann Vermeulen ............ ...... .................. J Notary Public Signature: .... l!l!!(....Ux(l1�............ My commission expires: .....08 / 28 / 20..2 ........................................................... • = aye OFFICIAL SEAL € Notary Public, North Carolina COUNTY OF DAVIE JO ANN VER ' EU EN My Commisslon Expires -2 Notary Seal