NCC231053_FRO Submitted_20230428

City of Winston-Salem Field Operations Department I Erosion Control Division
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Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
li1IlS10116akI'Jll 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: Murray Heights Subdivision
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: Murray Rd., across from existing Becks Ch. Rd.
Latitude: 36-09-14 N Longitude: 80-21-24 W
Approximate Date that Land-disturbing Activity will Commence: December 2022
Purpose of Grading:
❑ Commercial ❑ Residential Multi-family x❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑Other
Total Site Acreage: 20.99+/-Acres Acreage to be Disturbed: 16.52 +/-acres
Grading/Erosion Control Permit Fee: $ 3874
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Robert E. Weidl Email: [e-mail]
Office Phone: [phone] Mobile Phone: Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 6818-44-8854 Tax Block#: 014D Tax Lot#: 3491
Name: Alcoa Properties, LLC
Street Address/PO Box: 2806 Reynolda Road, Suite 172
City/State/Zip Code: Winston-Salem, NC 27106
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: $ 250,000 City of WS Contractor ID#: 81828
Name of Grading Contractor: Jack Shields Grading NC License#:
Contractor Contact Person: Mike Shields Contact Phone: [phone]
Street Address/PO Box: 4115 Glen High Rd.
City/State/Zip Code: Winston-Salem, NC 27107

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: Alcoa Properties, LLC
Street Address/PO Box: 2806 Reynolda Road, Suite 172
City/State/Zip Code: Winston-Salem, NC 27106
Office Phone: [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)
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: Robert E. Weidl
Title or Authority: Managing Member
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Signature: 1. 1�4�r%f d( /6-ZZ
^Date: �
I, KLia Q, ,CJ:M, ,a Notary Public of the County of.......C1c. Ntkh ,
State of..hJ�a,CAIN COzfolkna::,do hereby certify that f -N' VI ' .6\.. ,appeared
personally before me this day,and beingduly sworn,acknowledged that the above
form��was
�executed by him/her.Witness my
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hand and notarial seal,this �kh day of ...�...7e "'..."..( LJe( ,20 22
Notary Public Name: ....1\\‘Q..YTh1.e:... ..... . \1..e`� NICKIE PARKER
, '' ,,��``'' `� - / , NOTARY PUBLIC
FNotary Public Signature ,l..*A CI ...)% -' EO OF NOR H ARY
I STATE NORTH CAROLINA
6�- \Q- '62,' ; MY COMMISSION EXPIRES 04-12-2026
My commission expires: fiw. ea