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Home My WebLink AboutNCC222854_FRO Submitted_20220810City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 Muslon•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 553 Alpine Road ProjectName: ....................................................................................................................................................................................................... Grading/Erosion Control Permit #: 553 Alpine Road Locationof Land -disturbing Activity: ..... I ...................... I .......................................................................................................................... Latitude: ...... 36.0984.. .. Longitude:.....80.3384.. .................................................................................................................................... Approximate Date that Land -disturbing Activity will Commence: .........As soon as permitted ................................................................................................... Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ® Residential Single-family Lot/Lots ❑ Other 4.32 1.85 TotalSite Acreage: ...................................................... Acreage to be Disturbed:................................................................... Grading/Erosion Control Permit Fee: $.................................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Robert Wooten acecarwash@triad.rr.com Name: .................................................................................. Email:.................................................................................................................. Office Phone: ................................................... Mobile Phone: .... 336:399.5629........................ Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) 680547 851...400 Tax Block # 3909 Tax Lot #:.....0313 Parcel PIN#:........................................................................... ............................... .............. R3B LLC Name: ........................................................................................................................................................................ . .......................................... StreetAddress/P0 Box:......4001 COUNTRY CLUB RD UNIT K City/State/Zip Code: ............WINSTON SAL1=M NC 27104........................................................................................................................ Office Phone Mobile Phone: 336-399-5629 .......................................................................................................... Fax #:................................,................ Grading Contractor Information: (if known at time of'submitting the Erosion Control Plan for review) Value of Grading Contract: $........ nn�/0.c.�...................... City of WS Contractor I #:....... z 1............................................ Name of Grid n �iractoi �,:�G. �........................................... NC License #:....L2, % LC ................................................ Contractor }orltact. rsior' ...:............ Q � Contact Phone:.... .�...l.... Z�............... Street Addrelss/PQ-B. �1 ..C.� .......3.................................................................................... City/State/Zip Code:..... 5....... f r V.C............�2_21. . Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional person(s) or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Nameof Person or Firm:---.......R3B LLC............................................................................................................................ Street Address/PO Box 4001 COUNTRY CLUB RD UNIT K WINSTON SALEM NC 27104 City/State/Zip Code: ..................................................................... Office Phone: ................................................... ......33$.399.5629....................................................................... Mobile Phone: Fax #: If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Name of 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) Name of 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.) 1 agree to provide corrected information should there be any change in the information provided herein. Type or Print Name:............................................................ Robert Wooten for R3B LLC ............................................................................................... Member -Manager Titleor Authority: ...................a................................................................................................................... Signature:...... ............... ......................................................................... Date:....... -1.5. ...2. ................. I,....... Lam .....C.�......0-A..1... ......................................... . a Notary Public of the County of ..... Fofs ff ................. State of MEth cC 10Lma , do hereby certify that ......�.�L.C.Cf.. W 0.0. .N................ appeared personally before me this day, and being duly sworn, acknowledged that the above form wasexecuted by him/her. Witness my77 hand and notarial seal, this ................ . �............................................. day of ............. ��%.{! .�...................................... , 20 2 . -�- �oRa �. cRn�r Notary Public Name: ..... r.....J...�............. NOTARY PUBLIC TIC�,,� ��LNotary Public Signature : .............................. ......, ........... - - My commission expires: �. 1. �...��Dr... � a..1....... .......... Notary Seal