NCC240134_FRO Submitted_20240117

LID City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E. First Street,Suite 328,Winston-Salem, NC 27101
kl'llltihllltillll!I!l 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
WaSliProject Name: l Pansy
Grading/Erosion Control Permit#:Location of Land-disturbing Activity: 14 I U!'li Co)enn AvehIAe,' i SaleIV�.t 2 101
d L Q `-1 0 .... 11
Latitude: 34 fl 0�i'i �R?.3 G�if Longitude: ...Y�[. � 4�'R AA_ D I
Approximate Date that Land-disturbing Activity will Commence: I 1 I..1S..1'Z3
Purpose of Grading:
Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ ResidentialSingle-family Single++family Lot/Lots ❑ Other
ITotal Site Acreage: R - sakCr• Acreage to be Disturbed: 1.*0 AL'
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control relatedissues arise during land-disturbing activities:
Name: ..»)OItiCe M ) NNitrWoj L+t E?tl: j x4 A5cArWtIfin.<OMYI
Office Phonc ..6.'r' -7rr 285 Mobile Phone:_bk l-2-419$ Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
�i —IG'44t28 Tax Block#: 48.?4.1 {.k�2.:� Tax Lot#:
Parcel PIN#� � � "'•;
Name: etcPSSir15 A56°444+45) lrLc
StreetAddress/PO Box: 424 VS, Mvt, 1• in k
City/State/Zip Code: Kdrnersvi.Ile„� NL 2?2-$4
Office Phone: .166--216—.2285 Mobile Phone:^]. ?`...Z r ' L Fax#:
Grading Contractor Information: (iflcnown at time of-submitting the Erosion Control Planfbr review)
Value of Grading Contract: $ City of WS Contractor ID#:
Name of Grading Contractor: TBD 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***
Name of Person or Firm: -rgArk. \4254 Pariver6 ,..l.el4C
Street Address/PO Box: ....1.9.611. WoWe11 Mill 1E644 1.4#t2 7-I.0
City/State/Zip Code: ....,tte:10 !'a_�... ar5le, a318
Office Phone: 17.0--.35`VRa3(P Mobile Phone: Fax II:
If the financially responsible party is an out-of-state firm,provide information for
�the in-state registered agent:
Name of Registered Agent. C,�-v-ea'0•A't-• Cy -4-04i`9"r'S N o'• _" QY 'kr\C- .
Street Address/PO Box- 1S-1` Grp ^ , `~ `� - •v`'Q-+ -#'3
City/State/Zip Code: ,..CA-N \ "t I vC. 2'g2.1• `
``__ r
Office Phone: .5 1 • (P 14 • P 1 Q� 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) ^ n
Name of Registered Agent: �r..Ckr� 'm r--�.1a.10-vNe r /" `t .l.t)\&rv\ 't-,,
L
67— 2\\ M' 1 t0
Street Address/PO Box: 161.. .. . 1 .....1`�f�...f...�l�+a� �-
City/State/Zip Code: At kqw`'�VA GA 3 .3.1.-S"
kwi
Sifr Phone: 404•Q 11 ?: I i .I...... Phone: 7 7Q •3S9 •9 b 3b Fax/f:
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: ... `''1 F1k•-0.-%VkaA.A0N. `i
Title or Authority: /"`a`Ma C`--'-
Signature: Date: 1'01 1 it I/ 2mZ3 ,..
I, , w igyv-` — ` , a Notary Public of the County of
State o f,...GQlQ.lr.V 0••... , do hereby certify that.1 ..... O Y\ -Pia V\A' , appeared
personally before me this day,and being duly sworn,acknowledged that the above form was executedby him/her. Witness my
hand and notarial seal, this llli, day of ...0 c l2 — ,20 1-3
`\`��t%IIII //��''
•.AYBEN V{r ii
Notary Public Name: ...L.M :5elit 4,... .r)/. ��Yo.'M SSI0%,, 6_i=� 4 NOTd4•
Notary Public Signature: �o� �=r
A-
m:.>,, �911G f Q�
My commission expires: 2 l O eS.4 -isit.•• ��:
'.-I, ii.. ````