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Home My WebLink AboutNCC221529_FRO Submitted_20220420City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 Moon -Salem 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 Project Name:... Lyndon Steel New Truck Access and Laydown Yard Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity. .1945 Union Cross Road: �nSton-Salem: NC Latitude:..36:0449..................................................................... Longitude:.:80:13$6....................................................................... Approximate Date that Land -disturbing Activity will Continence: April 2022 ........................................................................................................... Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other TotalSite Acreage ....5:32.......................................... Acreage to be Disturbed: ... 4:4....................................................... Grading/Erosion Control Permit Fee: $.................................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: ..Sam Winters ..................................................... Email:..swinters@lyndonsteel:com......................................................... Office Phone:.(336) 785.Q848 „Mobile Phone:.(336� 413.6583 Fax #:....................... ................ .......................... Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #:...... 6863.37.1136: 6863 .37.4244 Tax Block #:.�0.62.i..................I..... Tax Lot #: 045E...04.5 D Name:....... Fs Log Cabin, LLC (6863-37-1136 & 6863-37-4244 - merged into Winston Steel, LLC) ......................................................................................................................................................................................... StreetAddress/PO Box: J 47 Union.Cross..Road........................................................................................................................... City/State/Zip Code: Winston :Salem:..NC...27107............................................................................................................I................. Office Phone: (33.6)..785-0848. .................. .... Mobile Phone ..... Fax # :................................................. ........................ Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $ ..................................................I City of WS Contractor ID#:.................................................................. Nameof Grading Contractor: ............................................................................. NC License#:................................................................ ContractorContact Person: .................................................................................. Contact Phone:............................................................... StreetAddress/PO Box: ..................................................................................................................................................................................... City/State/Zip Code: ........................................................................................................................................................................................... Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional person(s) or finns if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm: Winston Steel, LLC ......................................................................................................................................... Street Address/PO Box: .1947 Union ..Cross....Road. ............................................................................................. City/State/Zip Code: Winston-Salem.,..NC ......27107-6448............................................... . .. .. .. .. . . ....... . .... Office Phone: {336. 7$5-0848 Mobile Phone: Fax #: If the financially responsible party is an oat -of -state firm, provide information for the in -state registered agent: Nameof Registered A.gent:...............................................................................•................................................................. 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: ............................................. I ......................................................................................................... I ........................ Street Address/PO Box: ..... City/State/Zip Code............................................................................................................................................................ OfficePhone: .............................................. _... 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. Type or Print Name: By... FabSouth, LLC, Member/Manager; By: Sam Winters .............................................................................................................................................. Title or Authori ;Vice- e ide of FabSouth, LLC .. ............................... Signature: ........................ Z ......................................................................... Date:......1�. ...................... Ynad_arPj,, 1, ....... t......'.1........................................................................... . a Notary Public of the County of ... S. .......................... State of .t441' 1..Q,Srl�. l'? 4.. , do hereby certify that ..................Sam Winters................................ appeared personally before me this day, and being (duly sworn, acknowledged that the above formwasexecuted by him/her. Witness my hand and notarial seal, this ...............1. V.l.................................. ........... day of Awl .................................... 202'. Z.. Notary Public Name: ... CHRISTINE MACLAREN ......................... NOTARY PUBLIC Notary Public Signature: ...........` LLJ Forsyth County ........... .......................... North Carolina { ;{ My Commission Expires August 6, 202 My commission expires: J t............... o nay eu