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Home My WebLink AboutNCC216566_FRO Submitted_20211123STORMWATER/EROSION 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 fbet 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: -Gatehouse-Terrace------------ --------------------- Permit # Location of Land -Disturbing Activity: 2321 Old Salisbury Road (SR3011), Winston-Salem ------------------------------------------------------------------------------------------------- Latitude 36.0356 Longitude-80,2736 Approximate Date to Commence Land -Disturbing Activity:September 2021 . -------------------- ---------------------------------------------------- Purpose of Grading: Commercial Residential Multi -family Other (No development proposed) Residential Single Family lot Residential Single Family Subdivision Total Site Acreage: _10 10 _______________ Acreage to be Disturbed: Permit Fee: Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name John Gramberg info@elaminvestment.com --------------------------------------------- E-mail address ------- ---- Telephone ---(336) -339-2627 ---------------------------- Cell #----------------------------- Fax # -------------------------------- Landowner of Record (use blank page to list additional owners): Elam Guilford, LLC (336) 339-2627 N ---am---e -------------------------------------O-wn----ers---Phone # 6901 Maynard Road SirW-Ad-dr-e-s-s--PO--.--B-ox-------------------------------------- Summerfield, NC 27358 --------------------------------------------------------------- City/State/Zip Code ------------------------------------------------------------- Name Owners hone # ----------------- --------------------------------------------- Street Address/P.O. Box --------------------------------------- ---------------------- City/State/Zip Code Tax Block #: Tax Lot #: ____ Zoning: _RS9------------- Zoning Approval: ------------------- PIN Xs: 6823-24-9287; 823 6823-24-9156; 6-24-1231 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. Value of Grading Contract Name of Primary Applicant (Grading Contractor) Street Address/P.O. Box City/State/Zip Code City of W-S Contractor's ID # Contractor's N. C. License Number Contact Person for Contractor Contact Person's Daytime Phone Number PART B I. Person(s) or (inns 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. Elam Guilford, LLC ------- ofFi-------- ------------------------------------------ --------------------------------------------------------------- Name of Person or Firm Name of Person or Firm 6901 Maynard Road --------- ----------------------------------------------------- - Street Address/P.O. Box Street Address/P.O. Box Summerfield, NC 27358 City/State/Zip Code City/State/Zip Code (336) 339-2627 ----------------------------- - ----------------------------- -- Daytime Telephone # 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 -------Address/P.O.-------------------------------------------------------- Street Box --------------------------------------------------------- City/State/Zip Code ------------------------------------------------------ Daytime Telephone # 3 _Cf Ibe_6nancillly_ze&pt�n�ibJ� party is a partnership, give the name blank page to list additional partners). --------------------------------------------------------------- Name of the General Partner ---------•----------------------------------------------------- StreetAddress/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. Manager of ELAM Investments, LLC _Elam Guilford, LLC, By_ ELAM Investments, LLC, Manager___ •------------ I ----------------- --- ------------------------------------------------------------ Typ)rorPrint Name Title r Authority -: r------- -- ------------------------------------ ---- .--- -------------------- -------------------------------- Signature By: John Gramberg Date 1, K�J a __ ernon a Notary Public of the County of - 0. -----------�- - ----V ----------------- , -- ------------------------------- State of North Carolina, do hereby certify that ---__ Gra-m6ar_� 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 of My commission expires: _Q`____I_�_ta J v ne--------- 20 0��--- ' O�`��v �E�RNO��i, Nota' ry Publi- -"--- -------------��-_.��$AY ----- --- ON