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Home My WebLink AboutNCC230676_FRO Submitted_20230313City of Winston-Salem Field Operations Department I Erosion Control Division Office, 100 E. First Street, Suite 328, Winston-Salenz, NC 27tol V HSIMti531M 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 fonn 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 "NIA" in the blank space if not applicable. Part A Project Name: ... leylors.... Zt.i.. ,�, ;... Grading/Erosion Control Permit #:.M:Mr........... ................................................`.................................... ................. Location ofLand-disturbing Activity: ..�CY.�... .i:�lk�... � ...'.`�t:... �.... `4. !IJ.(4.... .�...:Y.�'�............I... ................ I......... Latitude:3543T-wa-7 ...................................................... Longitude:.....x.3�.) �,k?9.0a..... ... ............................... I ...... I...... Approximate Date that Land -disturbing Activity will Commence: ... 93-1...:.;'1............................................................................... Put pose of Grading: ❑ Commercial ❑ Residential Multi -family residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage:....�.�..,.. . ............................ Acreage to be Disturbed:................................................................... Grading/Erosion Control Permit Fee: $................:................. Person to contact shouldErosionControl related issues ariseduringland-disturbing activities: Name:...% ... lit T.:!........................................ Email:.: ,?s�^ 1; e? 9� t .�..... ?A................... Office Phone: ................................................... Mobile Phone:.1.,x�.kq:�..�.. 7....... Fax #:......<.......................................... Landowner of Record: (use blanr�k, page to list additional owners if needed) Parcel PIN #:.. g�.�:.�..!��.1..-. �. l o.�°�.p, 000 ........ Tax Block #:.... X.-4.............. Tax L.ot #:.. .............. Name: ..zr� .t ....!.ti ..l.....!c-a .. Y` '. ...}' t! ..Gm y.1.................................... StreetAddress/P0 Box: �iG��IP...� �.<.y.... ...................................................................................................................... City/State/Zip Code: ... `'v.........�...—.......................................................................................................... OfficePhone: ................................. . ................ Mobile Phone:.��.c?..it.3'.�1�....1........ Fax #:... ...... ........................................ Grading Contractor Information: (if known al time ofsubmitting the Erosion Control Plan_for review) Vallee of Grading Contract: $ .,tl 14 0............................ City of WS Contractor ID#:.................................................................. Nance of Grading Contractor:..��1!�..�lgS , 1�/I�.�...,t�.�.a................ NC License #:............................................ Contractor Contact Person: �y,,n#'�,i ....�,�t .......... Contact Phone:..3., acA -P StreetAddress/P0 Box:.. .� .Q.....`] . �.eb.................................................. ........ ................................................. City/State/Zip Code: ,,....... .............. ........ ............ ........................................................... Para 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 Tina ciya�lly responsible for property not under their ownership*** Name of Person or Fit -in: t�� c�f1.. .. 1 ., . JJ@�14?f l le,;& �Ot^�.,,, �L - u..... . ... ............ Street Address/P0 Box: ..6 :[2��.... wl j.()... ..... City/State/Zip Code: �lE�t'V�1 {?t �.l. •..QL......;�..ol'L......'................•.........•........................•.•.................................. Office Phone . .................................... ........... _. Mobile Phone: � ? 7j�.. :'..1.•1 1 1....... Fax #:.,............................................... if the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: ............................................... .......... I .......... I ....................... ................................................ Street Address/PO Box: ....... _ ...................................... ....... _ ....... City/State/Zip Code: ...................................... ................................................. . OfficePhone: ................................................... Mobile Phone: ................... .,...... ........................... Fax #: ................................................. tf the financially responsible party is a partnership, provide information for each General Partner: (use blank page to list additional partners if needed) Nanceof Registered Agent: ................................... __ ..... ............................................................................................................................... StreetAddress/PO Box:_., ..................................................... ,.............. .................................................. .............................•......................•...... City/State/Zip Code: .......................................... ................................................................................. __ ........................... OfficePhone: .............................................. Mobile Prone:...................................................... 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-izn-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......�C( `c'e`� ..................... •......................... I.• ....... ._.............. ........................ I......... Title or Authority:..', A( !�Si nature:�.. d.�............................................. Date . ..... �...........................•......... I . ........4Y!j .....1"k...................... ........................,....... , a Notary Public of the County of ....... F6YS ......................•. y State of ......gA , ..Hl.... Y�?��:t0.... , do hereby certify that .....6re.. l4./.' ..... P.reLX•�Y1t1..... G.� CC14... , appeared personally before me this day, anddfbeing duly sworn, acknowledged hat the above form was executed by him/her. Witness my hand and notarial seal, this .......•......... ................................................... day of ..................................., 20 Notary Public Name: ..................... 1� (ff�........................... �O A Y - Notary Public Signature: ...........rl......� ...V?�............ P U f - My commission expires: .................�st.1 +.... �s ....... '/��/// 7H1 � Seal City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 325, Winston-Salem, NC 27101 VAIIS11111,0111 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 thcsc 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 Name....... Salem Brooke Subdivision ....................................................................................................................................................... .......................................... Grading/Erosion Control Permit##:............................................................................................................................................... Location of Land -disturbing Activity: .,Frye Bridge Road (Sunny Brook Ct. & Salem.Place Dry Clemmons Township, ........................................ ........................................................... ...... Latitude: 35.99789-80.36492 Forsyth County, 27012 Long�tude............................................................................................. Approximate Date that Land -disturbing Activity will Commence: ........ Ma...... rch 1, 2023 .............................................................................................. Propose of Grading: ❑ Commercial ❑ Residential Multi -family x❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 13.55 +1- Acres Acreage to be Disturbed:...........10.26 +l- acres ......................... I........................... Grading/Erosion Control Pennit Fee: $ .................2662...DC .............. Person to contact should Erosion Control related issues arise during Band -disturbing activities: Name: Greg Garrett ......... Email: braxtonreanddev@gmail.com Office Phone: ....... 636.399.7197............... .. Mobile Phone.- .................................. ............... ..... Fax #: .......... ....................................... ........ Landowner of Record, (use blank page to list additional owners if needed) Parcel P1N#:...... 5892-6Q-0533.000...................................... Tax Block 4:........ 4,20.2 ................ Tax Lot #:.... 0036................... Narne:.................................Braxton Real Estate and Development Company. LLC Street Address/PO Box: ........ 6420 Hampton Knoll Road........................................................................................................................ City/State/Zip Code: .............Clemmans:..N�...27012................................................................................................................................ 3 Office Phone: ...... ....3....6.-...399-7197 .. ............................... Mobile Phone:...................................................... Fax #:................................................. Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for revie") Value of Grading Contract: $................................................... City of WS Contractor ID##:.................................................................. Name of Grading Contractor: ..................................... NC License #: ................... ............................................. ContractorContact Person. __ ............ ... ' ...... I ................................ .............. 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: (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 Firtn:..... RrMton Real Estate and Development Carnpanyy, LL ......_ ....... Street Address/PO Box: t34?9 Hampton Knoll Road ... .................................................. City/State/Zip Code:.......... Clemmons�..NC 2701.2......................................................................................................... Office Phone: ........ 336-399-7197.............. Mobile Phone:...................................................... Fax #:................................................. If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: ............. - .............................. ................. — .......................................................... ..................... StreetAddress/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) Nanceof Registered Agent: ........................................................................................ .. . .................................................................................. StreetAddress/P0 Box: ................................................................................... . ....................... ............. ......... ................................................. City/State/Zip Code: ............. Office Phone: ............... ............ Mobile Phone: ..................... Fax 4: ........... ................................ 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-ur-tact, or if not an individual, by an officer, director, partner, or registered agent with authority to execute instnunents for the financially responsible person.) I agree to provide corrected information should there be any change in the information provided herein. Type orPrint Name: .... GregoryB... Gar.r ..........ett ....................... Title or Authority:....... Managin Member.... Signature: ... A ... ............................................................................... ;2 Date: ..�h/1................................ f I . .............. !.......V': `...-660................................................ , a Notary Public of the County of .....(i�!r .. ...................... , �rr • j� f' . . State of .....f.- Y.'..:!...` �r0 1 �.e.1 �... do hereby certify that ... e dl' .... 2 t GlK t7?1 1 T ..... ,appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her: Witness ruy hand and notarial seal, this ....................... �.......................................... day of .. -vf&h! 1�W,,,-1 ................................ , 20 .. Notary Public Name: ........� ................................ Notary Public Signature: ..........T .................. My commission expires: 1 1 126! SPRY O `v z P�� 'i�'cORSyl� Seal