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Home My WebLink AboutNCC221472_FRO Submitted_20220414STORMWATERIEROSION 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 "NIA" in the blank space. PART A Project Name: Gatehouse Manor Permit # Location of Land -Disturbing Activity: "0" Pope Road Latitude 36,0407 Longitude Approximate Date to Commence Land -Disturbing Activity: July 2021 Purpose of Grading: 7comnierciai 7Residential Multi -family Other (No development proposed) Residential Single Family lot Residential Single Family Subdivision g 13.89 __ Disturbed: Permit Fee: Total Site Acreage: ---------------------- Acreage to be Distur _-----_--_--------� ----_--_-----------_-_--------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: John Gramberg Name _______-___ E-mail address info@elaminvestment.com Telephone (336) 339.2627 ----------- Cell #----------------------------- Fax # -------------------------------- Landowner of Record (use blank page to list additional owners): Elam Pope, LLC (336) 339-2627 Name Owners phone # Name Owners phone # 6903 Maynard Road _______..._ ----_----------------------.-------- Street Address/P.O. Box Street Address/P.O. Box Summerfeld, NC 27358 ------------------------------------------------------------- -- City/State/Zip Code --------------------------------------------------------------- City/State/Zip Code Tax Block #: 3840-_------ Tax Lot #: 243 -,---- --- Zoning: RS9------------ Zoning Approval : P I N # 6823-06-2028 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 City of W-S Contractor's ID # Name of Primary Applicant (Grading Contractor) Contractor's N. C. License Number Street Address/P.O. Box Contact Person for Contractor 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. Elam Pope, LLC ------- -------------------------------------------------------- Name of Person or Firm 69(3 Maynard Road -----.--»---------------------------------------------- Street Address/P.O. Box -- Summerfield, NC 27358 --------------------------------------------------------------- CityiState/Zip Code (336) 339-2627 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. -----------------------------.--------------------------------------------------- R Name of the e-gistered---------A-g-ent------------------------------- City/State/Zip Code Street Address/P.t7. Box Daytime Telephone # -- 1-If tbt-6r=ciaUy_respo Ug-pmjy is a partnership, give the name andaddras Qfe h�erieral-E'�utaerlltse blank page to list additional partners). --------------------------_....__----------------------------- Name of the General Partner ------ _--_--- ---- .---- ------------------__--------_ -_-_ Name of the General Partner --------------------------------------------------------------- Street Address/P.O. Box ------------------------------------------------._..--- Street Address/P.O, Box --------------------------------------------------------------- City/StatelZip Code ---— ------- ----- City/State/ZipCode ------------------------------- --- Daytime Telephone # ------------ ------_--_---------- 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.) 1 agree to provide corrected information should there be any change in the information provided herein. Manager of ELAM Investments, LLC Elam --.op P� ELAM Investments, LLC, Manager ----------- -Y------------------------------------------ -- -------------------------------------------- T e r Pri t Name -- Title or Authority -- -=-------------------------------------------------------�v---1-?�------------------------------------------------ ignature 13y: John Gramberg Date __ 5'v-1------------ , a Notary Public of the County of Vl� So(J State of North Carolina, do hereby certify that ----------UO 1, n ------------- 0��?° �------------------------------------------------ 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 ____I 4+6__day of My commission expires: :1_-_ �_�tc o� ------- w\\\\� Ni0tilr//ii��i'' N� -�� ------ —A------ oy ia,� J� Q 0. !lD1�"��.