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Home My WebLink AboutNCC221856_FRO Submitted_20220516City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 lAnslnn-Mem 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 "N/A" in the blank space if not applicable. Part A Project >ame .....Calvary.Hill Church of Greater Deliverance ............. ........................................................................................................................................... Grading/Erosion Control Permit #: Location of Land -disturbing Activity: 4709 White Rock Road Latitude: 36.1643.................................................................. Longitude:-80.2079 ....................... b............................................................................................ Approximate Date that Land -disturbing Activity will Commence: .............May.....2022 ......................................................................................... Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ® Other Total Site Acreage: ..... 8.65 ....................................... Grading/Erosion Control Permit Fee: $.................................. Acreage to be Disturbed:......... 28 ....................................................... Person to contact should Erosion Control related issues arise during land -disturbing activities: John Leecost F.mail tinyford250@yahoo.com Name- ........................................................... Office Phone Mobile Phone:.( 391-0885 Fax #:.................................................... :......................................................................... Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #:..... 6848.30.6906; 6848-40.1931 Tax Block # :.................................. Tax Lot #: ................................... ............ Name. Calvary Hill Church of Greater Deliverance, Inc. Street Address/PO Box: ... 4951 Manning Street ..................................................................................................................................... City/State/Zip Code: ..... Winston. S.a.lem ....N.C...271.0.5 .......................................................................................................................... Office Phone: Mobile Phone: �336) 391-0885 Fax #:................................................... ........................................................................... Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $ City of WS Contractor ID #:.... 8232...................................................................................................... Name of Grading Contractor: Clement Construction Corporation NC License #: ,,,,,67844 .......................................................................................... Phillip E. Clement, Sr. (336) 749-0629; (336) 661-2488 Contractor Contact Person: .................................................................................. Contact Phone:............................................................... Street Address/PO Box: 3735 Beeson Dairy Road ............................................................................................................................................................ City/State/Zip Code:.... Winston. Salem: NC....27105.............................................................................................................................................. 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: .... Calvary Hill Church of Greater Deliverance: Inc: Street Address/PO Box: 4951 Manning Street .................................................................................................... City/State/Zip Code: W.n.sto.n.-Sale.m, ..N.0 ...27.1.05....................................................................................................... Office Phone Mobile Phone: �336) 391 :0885 Fax #:.................................................... ................................................................... If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: .................................................................................................................................................. StreetAddress/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: ........................................................................................................................................................... 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: Calvary Hill Church of Greater Deliverance, Inc. (Claude C. Turner) ........................................................................................................................................................... Title or Authority: Senior Pastor .................................................................................................................................................. Signature:.`i.,......WZ—................................................ Date: .%.1:..�,......�........ 1 Kay W. Vernon , a Notary Public of the County of ...... Davidson ................................................................................................................ State of . Nq! th,.Carolina................... . do hereby certify that ..... Claude C.Turner , appeared .... ............... personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my hand and notarial seal this 11th day of .......November 20 21 O �P 2 Notary Public Name: ........Kay..W.. .Vernon ............ .................... NoTARY U IG =_ Notary Public Signature: _ Pue� My commission expires: April 11, 2022 �'%/ SON GOv��\ota Seal fi"q„"inunmwp\\', ry