The URL can be used to link to this page

Home My WebLink AboutNCC220607_FRO Submitted_20220203City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 ftshin, Jleni 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 "NIA" in the blank space if not applicable. Part A Salem Industrial - Lot 9 ProjectName: ............................................................................................................................... ............................... Grading/Erosion Control Permit#:..EN2200002..................................................................................................................................... Location of Land -disturbing Activity: 2452 , t, ............... Salem ................ Park ................Drive.....Wins .................................on-Salem.............NC .............27127.............................................. Latitude:...36:02$78$ Longitude:...-80.322784 ............................................................................................................................... Approximate Date that Land -disturbing Activity will Commence: 21.. /2022 Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other 3.130 2.20 Total Site Acreage: ...................................................... Acreage to be Disturbed:................................................ ................... Grading/Erosion Control Permit Fee: $ $1,046 Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: ...CoryGeorge.................................................. Email:.. cory.@pilotse:com....................................................................... Office Phone: Mobile Phone: 919-971-5619 Fax #:.......................................................I.......................................................................... Landowner of Record: (use blank page to list additional owners if needed) -9 Parcel PIN #:...6...8..03-81.........................859 ................................................. Tax Block #:.................................. Tax Lot #:................................... Name: ..ITAC 480, LLC, (Victoria Templeton)................................................................................................................................ Street Address/PO Box:....121 North Columbia Street...................................................................................................................... City/State/Zip Code: Chapel , ................................I............... ...........................Hill....NC.........27514.................................................................................................... Office Phone ...........919-945-2400 Mobile Phone: ....................................................................... Fax #: ...................................... ........... Grading Contractor Information: (if known at time ofsubrnitting the Erosion Control Plan for review) Value of Grading Contract: $................................................... City of WS Contractor 1D#:.................................................................. Name of Grading Contractor: ............................................................................. NC License#:................................................................ ContractorContact Person:.................................................................................. Contact Phone:............................................................... StreetAddress/PO Box: ..................................................................................................................................................................................... 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: GTE Properties ! I I, LLC (Greg Eb.ert).. .. . .. .... ....................................................................................... 3937 West Point Blvd StreetAddress/PO Box: .......................................................................... ......... ........................................... City/State/Zip Code: Winston-Salem, NC 27103 .......................................................................................................................................................... 336-403-4890 Office Phone: ................................................... Mobile Phone:...................................................... Fax #: If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: ............. ......... ...... ...... .................................................................................................... Street Address/PO Box: ............ __ ................................................................. City/State/Zip Code: ............................. .............................................................................................. .... .... ... .................... OfficePhone: ................................................... 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) Nameof Registered Agent: ................................................................................................................................................................................ StreetAddress/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. Greg Ebert Type or Print Name:............................................................................................................ .... ... ManagingM Titleor Authority. ....................................................................................l......... ................. Signature: .................................................................... Date:..l.. '. �. .................... TV� -�•�. I,.........��5do* ........`....`.v......, a Notary Public of the C ty of ...C!......'"'....., State of ..........Q ......L.:.'.�L�.... , hereby certify that .... CS .....EI ..... ............................ . appeared personally before me this day, and being duly sworn, ackn wUcdged that the above f I'm was executed by him/her. Witness my ............................ . hand and notarial seal, this .................................. day of ....1, , ..Fii.%..... .......................... , 20 Z3, Notary Public Name: 4 Notary Public Signature: My ission expires: Sella 9397 11110l2021 s5.00 Sella de Asislencia leaal WOM 2021-1110-06074018