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Home My WebLink AboutNCC221277_FRO Submitted_20220404City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 14b1SIUIISdIL911 Mailing: PO Box 25 t 1, 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:.Lewisvi..11..e..Post..Office.............................................................................................. ...............•---....................................... ...................................... Grading/Erosion Control Pen -nit #: ......................... Location of Land -disturbing Activity: 7011 Great Wagon Road, Lewisville, NC ............................... Latitude: 36d 06'04.1 "N ......... Longitude: 80d 24' 47.8W........................................................... ................................................................................ ........................ Approximate Date that Land -disturbing Activity will Commence: TBD.................................................................•,............................. Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 2..34 ............................................ Acreage to be Disturbed:.1.:8........................................................... Grading/Erosion Control Permit Fee: $.................................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Synterra Corp, Doug Mynear dmynearesynterracorp.com Name:..Kirkland: Inc: Sher�r Grooms .................................... Email: ..sgroom...... kirklandinc.corn....................................................................... ............ ........... ............ .. . ndin... . 859-608-7733 ................ Mobile Phone:..................................... Office Phone: ..33fi-454-6131................................. ............ Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) ParcelPIN #: .................................................................................. Tax Block #:.................................. Tax Lot #:............... Name: Maple Tree Investments Todd Conley ............................................. StreetAddress/PO Box: 2047 Grab Rd.:.................................................................................................................................................... City/State/zip Code: Greensburg, KY 42743....................................................................................................................................... Office Phone: 270-932-1876 .. Mobile Phone: .......... Fax # ........................................ .................................................................... Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $ 163;000................................ City of WS Contractor iD #: 81768............................................., *... Name of Grading Contractor: DAK Gradln�.............................................. NC License #: .09.177-9 ............................................ Contractor Contact Person: Sherrar Grooms ..................•„ Contact Phone 336-454-6131 „• ........................................................................................... Street Address/PO Box: 4140 Mendenhall Oaks Pkwy . ,.....,. . , , ........ ,, .... ..... .......................................................................... City/State/Zip Code: .Hi0Po.N.0 .2.7265. .............................................................................................................................................................. Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional persons) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Narne of Person or Firm: Maple Tree Investments ............................................... ................................................................................................ Street Address/PO Box: 2047 Grab Rd. ........................................................................ City/State/Zip Code: Greensburg, KY 42743 Office Phone: 270-932-1 876................... Mobile Phone: .............. Fax #: .?TQ-93.2-1.8.7.6 ................... ......................................................................................... If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Name of Registered Agent:Pejortl Conley ...................,........................................... ....................................................... Street Address/PO Box: 2047 Grab .R...d............................. .........................................................................•....................... City/State/Zip Code: Greensburg, KY 42743 .......................................................... Office Phone: 270-932-1876 Mobile Phone: 270-932-1876 ...._.------„_... Fax #: .27.0-93.2-1.8.7.6 ................... ................................................. 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: Todd R.Conley................................ ........................................................................................................... Street Address/PO Box: 2047 Grab..Rd.. ........................................................................................................................................................... City/state/zip Code: Greensburg, KY 42743 Office Phone: 270-932-1876................... Mobile Phone: -270-932-1876...................... 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: %�t� I Title or Authority .. .... . 1 d t- .................................................................................................................................. Signature:............................................................................ Date: D3 [j V f ZOZ-Z 1.......................................................................................................... . a Notary Public of the County of ................................. I .................. p State of .................................................. . do hereby certify that................................................................................. , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my handand notarial seal, this........................................................................... day of.................................................................. , 20 ........... Notary Public Name: ............�-... �`i`Q. �:. �.......... Notary Public Signature: .................................. ...... - My commission expires: ............................a...ao.......aq ....................... KYNP a(Pg5 " Laura Jean Ham Notary P'ut>Hc State at La , K W Cannbn Emit on - - Notary Seal