HomeMy WebLinkAboutNCC231910_FRO Submitted_20230621 AP
City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
WblSIOD PIII 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
Woodhaven Subdivision
Project Name:
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 6197 Stanleyville Drive
Latitude: 36.2241 N Longitude: 80.2559 W
Approximate Date that Land-disturbing Activity will Commence: May 1,2023
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
El Residential Single-family Lot/Lots ❑Other
Total Site Acreage: 16.9 Acres Acreage to be Disturbed: 5.8+/ Acres
Grading/Erosion Control Permit Fee: $ $1,s52(6 acres)
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Randall Dunstan randy@dunstonproperties.com
Name: Email:
Office Phone: (719)659-0536 Mobile Phone: (719)659-0536 Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 6920-92-8000 Tax Block#: 4952 Tax Lot#: 105
Name: Randall Scott Dunston
Street Address/PO Box: 386 Rock House Road
City/State/Zip Code: Winston Salem,NC 27127
Office Phone: (719)659-0536 Mobile Phone: (719)659-0536 Fax#:
Grading Contractor Information: (f known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: $ City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/PO Box:
City/State/Zip Code:
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***
Dunston Properties,LLC
Name of Person or Firm:
Street Address/PO Box: 386 Rock House Road
City/State/Zip Code: Winston Salem,NC 27127
Office Phone: (719)659-0536 Mobile Phone: (719)659 0536 Fax#:
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:
Office Phone: 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)
Name of Registered Agent:
Street Address/PO Box:
City/State/Zip Code:
Office Phone: 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-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: 4/;Q.��jt,'V l alit Ion W 1
Title or Authority: DtAlt‘zr.
Signature: • ... Date: 1/((Z1 7
I, Cer-cr )" r s... , a Notary Public of the County of c—Ot�kittc
State of C1,ro t 14° , do herebycertifythat �n '4�( D t4' bv1 , appeared
p
personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her.Witness my
1 .
hand and notarial seal,this !..1..c day of S ,20 .......
Notary Public Name: 4! r-eAr 3 V 0t a COREY SHOUSE
Notary Public-North Carolina
COUNTY OF FOR H
Notary Public Signature: L.✓"- �r o �rw:_�y
My commission expires: ( / 2� iZQLI Notary Seal