NCC243750_FRO Submitted_20241206

' 1 City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
WinstnnSalem 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
Project Name: Hillcrest Townhomes Phase 2
Grading/Erosion Control Permit#:
Location of Land disturbing Activity: 1725 Eagle Creek Drive, Winston-Salem, NC 27103
Latitude: 36.054502 Longitude: -80.323702
Approximate Date that Land-disturbing Activity will Commence: 11/18/2024
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
® Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 9.36 Acreage to be Disturbed: 1.36
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Chelsea Ferrara Email: chelsea.ferrara aOlennar.com
Office Phone: Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#.6804-81-9374 Tax Block#: 3900 Tax Lot#:405C
Name: Millrose Properties North Carolina, LLC
Street Address/Po Box: 15720 Brixam Hill Avenue #300
City/State/Zip Code: Charlotte, NC, 28277
Office Phone: [phone] 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 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***
Name of Person or Firm-
eL nnar Carolinas, LLC
Street Address/PO Box:
6701 Carmel Road, Suite 425
Charlotte, NC 28226
City/State/Zip Code:
704-759-6000
Office Phone: Mobile Phone: 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)
Corporate Creations Network Inc.
Name of Registered Agent:
15720 Brixham Hill Avenue #300
Street Address/PO Box:..
Charlotte, NC 28277
City/State/Zip Code:
561-694-8107
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.
Mark Henninger
Type or Print Name:
Division President
Title or Authority:
.dic. ......‘.......j.Signature: •••1------N.... Date:
41,t.. LA CLAM rrl t (-13 a Notary Public of the County of Cobr((_A S .
State of Vbffilk C-4(61/0A , do hereby certify that.Mar Irn- Renn‘rwe—„ appeared
personally before me this day,and being duly sworn,acknowledged that the above form was executed by him/her.Witness my
ail.,
Novei-Abo-- , 20 2-ii-t
hand and notarial seal,this I day of
Notary Public Name: ts'ILlia. Cum ri (Y -5 MELISA CUMMINS
NOTARY PUBLIC
Cabarrus County
Notary Public Signature: North Carolina
My CommIsslon Expires July 4,2028 I
My commission expires: 3k4_1.3 LI( 2D2-e Notary Seal