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Home My WebLink AboutNCC222143_FRO Submitted_20220628W0 City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WHSINSWIll 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 CAROLINA'S VINEYARDS & HOPS ProjectName: ....................................................................................................................................................................................................... Grading/Erosion Control Permit #: Activity: 734 GATEWAY VINEYARDS AVENUE, WINSTON-SALEM Location of Land -disturbin g ty:............................................................................................................................................................. Latitude: .... 36.0804................................................................... Longitude:.-80:2435....................................................................... Approximate Date that Land -disturbing Activity will Commence:.. U N E 2022 ............................................................................................................ Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 2.83 acres Acreage to be Disturbed: 2. 03 acres ..2......... acres ....................................... Grading/Erosion Control Permit Fee: $.................................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: Christopher Megginson Email: info@carolinasvineyardsandhops.com ............................................................................................................ Office Phone: Mobile Phone: (336) 448-1284 Fax #................................................... ............................................................................ Landowner of Record: (use blank page to list additional owners if needed) 6835-20-5450 ParcelPIN #:............................................................................... Tax Block #:.................................. Tax Lot #:................................... Name:.gateway Sustainability Village,..LLC.................................................................................................................................... Street Address/PO Box:. 1111 South..Marshall........Street..., ..Suite.....184......................................................................................................................................... City/state/zip Code: Winston-Salem...,.NC....27101... .......................................................................................................................................................... Office Phone: Mobile Phone: 448.1284 Fax #..................................................................................................... Grading Contractor Information: (if known at time of suhmitting the Erosion Control Plan for review) Value of Grading Contract: $................................................... City of WS Contractor ID#:.................................................................. Name of 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 firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm:., Gatewax SuStalnablllty Village, LLC ........................................................................... Street Address/PO Box:..1111 South Marshall Street.Suite 184 ................................................................................................................................ City/State/Zip Code: Winston.Salem, N.... C 27101 ......................................................................................................................... OfficePhone: ................................................... Mobile Phone:.�336� 448-1284................... 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: ................................................................................................................................................................................ 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, Christopher Megginson (Gateway Sustainability Village, LLC) ............................................................................................................................................ Title orAuth M. Manager ......................................................................................................................................... Signature: ..................'....... ...... Date:....s ..I...(...7�.r............... I Kay. Vernon ...................... Davidson a Notary Public of the County of ...................... ....................... State of Narth.Carolina,,, do hereby certify that .............. Christopher Megginson appeared .............. , ..... pp 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 .........1 1 th........................................................ day of .....Mai,.................................................. , 20 2.2...... 4R Nrlp Notary Public Name: Kay W. Vernon EA,Notary Public Signature:k My commission expires: �.l.. 4J�� t" �1 o .� Notary Seal /')SotA 0\\`�`�� i3'