NCC240248_FRO Submitted_20240129

City of Winston-Salem Field Operations Department I I roslon Control Division
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11MIgMI Matlmg Pt1110m !CI I, \\'n1s101n Salem, Nt )II11!
Financial Responsibility/Ownership Form
'Va r ''s`n mat urinate am land-d►elurbing actnily exceeding !0,111111%wine lee' fin Single-Nnnlily Dwelling construction, IO,00(1
r.quarr fro kw am %dhet non-elempl purpose,of part of n linger i•onmron plan of development exceeding there Ihrexholdx, helOre this
hum and an*wept able I.1'0%111('o1111rl Plan hnr•'been eubnrined, reviewed,and approved by the('It y of Winston-Salem Erosion
l'ontm) On Peron and a firstling tmeron('ptlll\d I t91nil has been Ivvur'd Please Type or print. Please place"N/A"in the blank ~pace if
n.d aprhrahle
Part A
Spedrdleur MIN Rd. - Snyder Farm Rd. Subdivision
Ile t Name .... ... . ...
inktnng 1,mt¢Mn l\irl TO' PeMlll M
°camp c+t l aid-diatWMng Activity S 714 SPAINNOUR Mill RD PIN:5991 03-1297
Latitude W 15'S.2f"N Longitude: 23'23.91"W
Approszynasse hate that Land-disturbing Activity will Commence:
9/1/2023
Purpose of Ursding.
❑Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
® Residential Single-family Lot/Lots [' Other
Total SawAeieage: 3 _ Acreage to be Disturbed: 3'84
Grading fusion Control Permit Fee: $
Per to contact sold Erosion Control related issues arise during land-disturbing activities:
Na>•c. Shams Watson Email: [e-mail]
Office Phone: Mobile Phone: [phone] Fax#:
Leer of Record: (use blank page to list additional owners if needed)
PR�d PIN#: 9991-03-1297 Tax Block#: 4728 Tax Lot#: 20
Name: TWIG,WCName:
SawAgicinrssipoRai 431 Brentwood Rd.
CrySaetel7�Code: Walston-Salem,NC 27107
Oboe Phase: Mobile Phone: [phone] Fax#:
Grating Ceitrader Iafvrea> on: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract S .. 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***
DIA Construction
Name of Person or Finn:
Street Address/PO ltox 431 Brentwood Rd.
City/State/lip Code: Winston-Salem,NC 27107
Office Phone: Mobile Phone: [phone] Fax#:
If the financially responsible party is an out-of-stale firm, provide inl'ortuation for the in-state registered agent:
Name of Registered Agent.
Street Address/Pt)Box.
City-State/Zip Code:
Office Phone: Mobile Phone: Fax#:
lithe 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: \.G..o. l.).Ci.\1
Street Address/PO Box: -1$) ?..Y..:t.,Y•} '--) Q.ct.�i' c 4
City'State/Zip Code: \M % hS:}C r. S‘7.--k e_vvi t,C, 1,-1 I v 7
Office Phone:Y30-(.6 . —5 31 1 Mobile Phone: ....3 to- c,)?.?;—5 3 7 7•.• 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.
T�pe or Print Name: g-`-k 6.4'+ ..J.i 0.(1
Title or Authority: I Y\°' `1-
' 5\Signature: Date: 5
1, ,._ .,,. a!-e se4-1 6 • 40"""`r ,a Notary Public of the County of 1":fiord
State of /v 44''" , do hereby certify that fit,t'"` 1.4., ,appeared
personally before me this day,and being duly sworn,acknowledged that the above form was executed by him/her. Witness my
hand and notarial seal,this Z 9 day of Aj7/ ,20 Z.
��,�'••�••a.. SAMUEL G. COMER
Notary Public Name:
.�Lw,y.d 6. ecume. � _.'•'�?`. Notary Public
�,�;;�r`J North Carolina
Guilford County
Notary Public Signature: /
My commission expires: 0'fl ���� Notary Seal