NCC221964_FRO Submitted_20220525

STORMWATER/EROSION CONTROL DIVISION
100 East First Street, Suite 328, Winston-Salem, NC 27101
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: --Fiddlers Green -------------------------------------------- Permit # ------------------------------------------ --------
Location of Land -Disturbing Activity:
Latitude 36.060327
---Winston-Salem,-NC __
--------------------Longitude-80�4185675'---------------------------------------------
Approximate Date to Commence Land -Disturbing Activity:
Purpose of Grading: 9 Commercial
9 Other (No development proposed)
__ October 2021
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9 Residential Multi -family
9 Residential Single Family lot
9 Residential Single Family Subdivision
Total Site Acreage: ____ 21.75 __-_________ Acreage to be Disturbed__ 17.45 Permit Fee:
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Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Anthony Lester [e-mail]
------------- ------- --------------- E-mail address ---------------------------------------
Telephone [phone] _____________ Cell # __-336_ 382.4416 Fax # _-336 _854-8876-----_-__-_--
------------------------------------------------ Fax
of Record (use blank page to list additional owners):
_r-AN r►-------------------------------------------------------
Name 333Z -- Owners phone #
V0v CAM ®EN _ �4 = 5 ---- t2cl,�c----------------
Street Address/P.O. Box
_ 64- WS/Mo NC- Z1 yl ----------------
-------
---- -----
City/Sta-te/Zip-Code-------
Tax Block #: Tax Lot #:
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Name Owners phone #
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Street Address/P.O. Box
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City/State/Zip Code
Zoning: ................... Zoning Approval: ...................
Contractor Information Required Prior to Permit Issuance
North Carolina State Caw 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.
Value of Grading Contract
Name of Primary Applicant (Grading Contractor)
Street Address/P.O. Box
City/State/Zip Code
City of W-S Contractor's ID #
Contractor's N. C. License Number
Contact Person for Contractor
Contact Person's Daytime Phone Number

PART B
1. Person(s) or firms wtio 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.
Fanning LLC
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Name of Person or Firm
1819 Rolling Road
Street Addres-s-W . Box ------------------------------------
Greensboro, NC 27403
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City/State/Zip Code
336-382-4268
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Daytime Telephone #
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Name of Person or Firm
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Street Address/P.O. Box
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City/State/Zip Code
-- _y_ti ------------------------------
Daytime Telephone #
2. If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent.
---------of-----------------------------------------------------
Name the Registered Agent
e -------------_s_s_ --.Box------------------------------------------
Street Address/P.O
---------------------------------------------------------------
City/State/Zip Code
---------------------------------------
Daytime Telephone #
3.-i£I.be,.6i=cially-resppjLSibkprty is a partnership, give the name ancL dz� e hSr�i x�l i;'aiTp�r.(use blank page to list additional
partners). _
--------------------------------------- --1 L(- STYL(1 F Cf_S
Name of the General Partner Name of the General Partner
. �g!q IUSLL/V - �------------------------------------ Flu s____________________________ _
Street Address/P.O. Box Street Address/P.O. Box -
------------------------- --G !�f srus-'A=----�_2 �Lo
- ------------------------------
City/State/Zip Code City/State/Zip Code
------------
_ z _S-^f-3_o_ m?----------------.
Daytime Telephone # 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
should there be any change in the information provided herein.
-_- °%-=Sl1tLV__{S-------------------------------------- M Ak1Cr�ti!(r /�%fi �
Type or P ' t me Title or Autho it
---------- -----------------------------------------------------------7 - --------------------------------------
Signat Date
1'------�i�+l�Pi1.A__�1.__ C4!4s►i �r.l.------ . a Notary Public of the County of--------�zti r-Aam,�--------------------------------
State of North Carolina, do hereby certify that AoG___l gmv"s__________
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 --22 b -----
day of ____S �Q,� ¢ R 20 _ 2�
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My commission expires:
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