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Home My WebLink AboutNCC216309_FRO Submitted_20211112STORMWATERIEROSION CONTROL DIVISION 100 East First Street, Suite 328, Winston-Salem, NC 27101 Financial Responsibility/Ownership Form Erosion Control Ordinance No person may initiate any land -disturbing activity exceeding 20,000 square feet for a single-family dwelling or 10,000 square feet for any other purpose, before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Erosion Control Section of the City of Winston-Salem/Forsyth County Inspections Division. Please type or print. If a question is not applicable, please place "N/A" in the blank space. PART A Project Name: Three R Mobile Horne Park Expansion_____________ Permit # Location of Land -Disturbing Activity: 170Jones Road, Winston_Salem, NC______________________________..----------_--_-__-___ Latitude 36.00 degrees Longitude 80.21 degree. Approximate Date to Commence Land -Disturbing Activity: June 1st, 2021 Purpose of Grading: 9 Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot 9 Residential Single Family Subdivision Total Site Acreage: 23.84 - Acreag,e to -be Disturbed-- 7.49 AC___ Permit Fee_:_$Zr056____________________ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Timothy S, Kenv_et1y,.,E-------------- E-mail address timoAy.kennerly@kennerlyengineering.com Telephone (336) 775-2118 -------------- Cell #(336)_655p3839----------- Fax # (3.36)_7k1-Q79_7_--------__-__ Landowner of Record (use blank page to list additional owners): Jones Estates Three R, LLC 919-908-6603 ---------------------------------•---- ------------ --------------------------------------------------- NameOwners phone # NameOwners phone # PO Box 14466 Street Address/P--- Box ----------------------- ---------- Durham, NC 27709 ------------- iWC__--------------------------------------------- City/State/Zip Code Tax Block #: Tax Lot #: _____________________________________ Street Address/P.O. Box ------ a ----- Co-- ---------------------------------------- - e/Zip City/S Zoning: MH _ Zoning Approval: Contractor Information Required Prior to Permit Issuance North Carolina State Law requires that contractors be licensed to perform work valued at .$30,000 and higher. All contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. i. : 111 Value of Grading Contract _Stackhouse Development Name of Primary Applicant (Grading Contractor) 2310 S. Miami Blvd Street Address/P.O. Box Stackhouse Development ,- I City of W-S Contractor's II) # 83940 Contractor's N. C. License Number Mike Karpinksi Contact Person for Contractor 337-339-8302 City/State/Zip Code Contact Person's Daytime Phone Number PART B 1. Person(s) or firms who are financially responsible for this land -disturbing activity (use blank page to list additional persons or firms). Contractors are not considered financially responsible for property not under their ownership. Jones Estates Three R, LLC or Fir ---------------------F- it ------------------------------------- Name of Person m PO Box 14466 --------------------------------------------------------------- Street Address/P.O. Box Durham, NC 27709 i�i`l�iiia"ie`/ii_� i� Code 919-908-6603 Daytime Telephone # --------------------------------------------------------------- Name of Person or Firm --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code ------------------------------------- Daytime Telephone # 2. If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. --------------------------------------------------------------- --------------------------------------------------------------- Name of the Registered Agent City/State/Zip Code ------------------------------------------------------------- --------------------------------------------------------------- Str-eet A-ddress/P.O. Box Daytime Telephone # 3-Ltthe_8nainciaUy-resp.ojm bJ.f,-- pAriy is a partnership, give the name blank page to list additional partners). - -a------------------------------------------------------------ Name of the General Partner --------------------------------------------------------------- Street Address/P.O. Box ------------•--------------------------------------------------- City/State/Zip Code ----------------------------------- Daytime Telephone # -------------- ------------------------------------------------ Name of the General Partner ---------------------------------------•------------------------ Street Address/P.O. Box ---------------------------------------•------------------------ City/State/Zip Code ------------------------------------- Daytime Telephone # 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 his 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. ___ Jonathan Gindes ___Manager__________________ ___Jqnathan ' ------------------------------- Type or Print Name Title or Authority Signature------- ------------ ----------------------- Date --------------- -� ----�� ------------------------ I, ---- e�. SSck- -- � th�,�1--- , a Notary Public of the County of---L'�`-=6---------------------------------------- ---- --- --- - - State of North Carolina, do hereby certify that __ ei1a�! ------ ___ _ �_____________________________________________ appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this day 20 y of - ------------ - --------------------- MELISSA SOLOMON Notary Pu My commission expires: ___NJgt@ry_F_LL lUc,,_Llgrth_Q.PnQUn.P_ Wake County My Commission Expires March 30, 2025