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HomeMy WebLinkAboutNCC233734_FRO Submitted_20231219 L511 City of Winston-Salem Field Operations Department Erosion Control Division Office: 100 E. First Street,Suite 328,Winston-Salem,NC 27101 WinslmlSalem 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 it' not applicable. Part A Project Name: Sentry Pointe Apartments, Phase 1 Grading/Erosion Control Permit#: Location of Land-disturbing Activity: PIN 6824 10 6785, Sentry Pointe Lane Latitude: 80.28056 W Longitude: 36.05333 N July 2023 Approximate Date that Land-disturbing Activity will Commence: Purpose of Grading: ❑ Commercial ® Residential Multi-family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots LI Other 11.73 5.87 Total Site Acreage: Acreage to be Disturbed: 1,652.00 Grading/Erosion Control Permit Fee: $ Person to contact should Erosion Control related issues arise during land-disturbing activities: Name: DAVIP JASON TfitL4T Email: TP0141egoFRALININC. CGM Office Phone: S H °•2 D N-41 2 4 Mobile Phone: 4 D Z'? 30 1 1 Fax#: 5 4 0-2 P 4'II Z 4 9 Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN it 6824-10-6785 Tax Block#: Tax Lot#: Name: BEF Winston Salem,t_t_C Street Address/PO Box: 5211 South Concourse Drive City/State/Zip Code: Roanoke,VA 24019 Office 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: fl E P W 1,1t S f CAI SA L ENI1 L L C Street Address/PO Box: f Q 9 403 8 e City/State/Zip Code: R O A K o H F VA '9 P ( Office Phone: H 0"2 0 4- 9 2 y t Mobile Phone: 5 a^ 5 3 'S © Fax #: If the financially responsible party is an out-of-state firm, provide information for the in-state registered agent: Name of Registered Agent:..PA AA CO RP IN CO R?OR a rE p Street Address/PO Box• 260 y 6 4 T e w A Y O A ;U O1:41 VET del l TE I o0 City/State/Zip Code: SAC 144 M E M'TO/ C A q$$3 3 Office Phone: gee-5' +2 t 2 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: g D ER Tf�At frV Title or Authorit • MA 46 F Signa -e: Date: ..OfrO--216L� I, t0151E4 PE(,ANe VI,IR , a Notary Public of the County of 'ROA NCR E State of VIP. IN(A do hereby certify that..J ClE IR i F RA I-IN , appeared personally before me this day, and being duly sworn,acknowledged that the above form was executed by him/her- Witness my hand hand and notarial seal, this Flit of (/ E , 20 .Z3..... Notary Public Name: it(Pk I y TEN V E LANE VIA g r KRISTEN DELANE \PAR NOTARY PUBLIC Notary Public Signature: �[yT EN 1r Ll�ME V(A . REGISTRATION#7234721 COMMONWEALTH OF VIRGINIA Z'31_2d 1 5 MY®OMMISSION EXPIRES My commission expires: