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Home My WebLink AboutNCC230617_FRO Submitted_20230308City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 MR10115i M 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: ...... Sale.m Brooke Subdivision........................................................................................................................................... .... ............................... Grading/Erosion Control Penuit #: ..... Ft v Z.�X�j............................................................................................................................................................. Location of Land -disturbing Activity: ..Fra/e Bid a Road.,�Sunn Brook Ct: & Salem Place Dr) Clemmons Township, ............ ... .............. ............ ..................... 35.99759-80...36492 Forsyth County, 27012 Latitude: ......................................................................................... Longitude:.......................................................................................... Approximate Date that Land -disturbing Activity will Commence M arch 1, 2023 Purpose of Grading: ❑ Commercial ❑ Residential Multi -family Cl Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 1.155 +/- Acres „_.. Acreage to be Disturbed:.....26......1.0.+l" acres Grading/Erosion Control Pennit Fee: $ .......2662' DO ........................... Person to contact should Erosion Control related issues arise during land -disturbing activities: Name Greg Garrett ...... Email: braxtonreanddev@gmail.com .................................................................................................................................................................. Office Phone: ....... 33 -399-7197............... Mobile Phonne:...................................................... Fax #:................................................. Landowner of Record: (arse blank page to list additional owners if needed) Parcel PIN 4:............................................ Tax Block #.. ........ 4202................ Tax Lot #:..... 0036................... Name: Braxton Real Estate and Development Compan�r: LLC ............................ .... .... ............ .... .... ................................................................ Street Address/PO Box: ........ 6420 Hampton Knoll Road........................................................................................................................ City/State/Zip Code: .............Clemmons: NC 27012............................................................................................................................... Office Phone:...... 336. 399.-7197 Mobile Phone: ... ......... ......................................... Fax #:................................................. ... ................ Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $................................................... City of WS Contractor .1D#:.................................................................. Nameof Grading Contractor:............................................................................. NC License#:................................................................ ContractorContact Person: ............................. .................................................... Contact Phone:............................................................... StreetAddress/PO Box: ......................................... ........................................................................................................................................... City/State/Zip Code: ............................................................................................................ . ...... .................................... ................................. `Part B Pei'son(s) or firms who are financially responsible for this land -disturbing activity: (rise blank page to list additional persons) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Finn: ..... Braxton, Real Estate and Devetopment.Company� LLC................................................... ...................I......................... ... ....... Street Address/PO Box:...... 6420 Hampton Knoll Road................................................................................................... City/State/Zip Code :...................................................lenS; NC 27012. .................................................................................................... Office Phone: ........ 336-399-7197............... Mobile Phone:...................................................... Fax #:................................................. If the financially responsible party is an out-of-state firm, provide information for the instate registered agent: Nameof Registered Agent: .................................................................................................................................................. StreetAddress/PO Box: ....................................................................................................................................................... City/State/'Zip Code: ..................................................................... ................................................................................ OfficePholze:................................................... Mobile Phone:...................................................... Fax#l:................................................. 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 -tact, 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 Gregory. B...Garrett ........... ...................... .............. ... .. Title or Authority:....... Manakin Member............................................................... Signature., V. .....6.t.............................................................................. Date:...../. ..l ................................ �5 I . ..............�� ........V . . �.............................................. , a Notary Public of the County of ......�, .S.. �?....................., '' State of .....I.ymY4.l� �� tl0\. , do hereby certify that �'re4 ��.... retKkon c��-� i'� T'�:......... ,appeared .. ..... .... personally before me this day, and beingdulysworn, acknowledged that the above form was executed by hirn/her. Witness my hand and notarial seal, this .......................Q.. ... day of ......&� , 20 a ....................... /.................................. J j% 1 � Notary Public Name: ........� ......1!.mb..Q ......................... O.� P R y J f •- Z Notary Public Signature ��—' p U� ............................................................. rah a�a� Gam My commission expires: .......................... .. /Y, .................._.... ''�`%,�ORsY1 \Seal