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Home My WebLink AboutNCC223160_FRO Submitted_20220909City of Winston-Salem Field Operations Department I Erosion Control Division Office: 1001 . first Street, Suite 328, Winskon-Salem, NC 27101 1iji151U11•Si11P111 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 Dart 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/F.rosion Control Permit has been issued. Please type or print. Please place -N/A" in the blank space if not applicable. Part A Project Name: ...Specialized..........Mobile.......Exhibits........Phase........................ 3.................................................................................................................. ................................ Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity:2422 Salem Park Drive Winston.Salem, N..27127 Latitude: ..36;03............................................................................. Longitude: -$0 32 Approximate Date that Land -disturbing Activity will Commence: ..September 2022.................................................... I......... Ptirl)ose of Grading: ><Commercial ❑ Residential Multi -fancily ❑ Residential Single-family Subdivision ❑ Residential Single -fancily Lot/Lots ❑ Other Total Site Acreage: 5.138+/- GradinglETosion Control Permit Fee: $.................................. Acreage to be Disturbed: ..5.11 Ac. Person to contact should Erosion Control related issues arise during land -disturbing activities - Name: .1oby,Rq.b.e.rt.so.n Email: ..trobertsnn@engages►n ........................................................................................e.com................................................................. Office Phone: „(336) 717 :9175 ..... Mobile Phone:., (336) 406-2323 Fax #: .............................(.3.3.6).40.6.-.2323 .......................... ................................................. Landowner of Record: (use blank ))age to list additional ntt,ners if needed) ParcelPIN #:..6s03,92;5133............................................... I........ Tax Block #: ........... ....................... Tax Lot#i:................................... Name: .... TW Aura Properties, LLC...................................................................................................................................................................... StreetAddress/PO Box:.. 2427 Salem Park . Drive . .............................................................................................................................................................. City/State/Zip Code:....eston.Salem, NC 27127 ..................................................................................................................................................................... Office Phonc: (336) 717.9175 Mobile Phone: ............................... (336) 4q6-2323 ....................... Fax #:................................................. Grading Contractor Information: (l f kno)vn at time of submitting the Erosion Control Ylon for revieti) Value of Grading Contract: $................................................... City of WS Contractor ID#:.................................................................. Nacre of Grading Contractor: ................................................................. . NC License#:................................................................ ........... ContractorContact Person:.................................................................................. Contact Phone:............................................................... StreetAddress/PO Box: ................... .... I ........................ I ...... I ... ....".. ...... '..' ................................................. I .................................. I ........ City/State/Zip Code: ..................................................................................................................................................................................... Part B Person(s) or firms ► ho are financially responsible for this land -disturbing activity: (use blank page to list additional person(s) or fir€ns if needed) ***Contractors are not considered financially responsible for property not under their ownership*** Name of Person or Firm:..? W Aura Properties, tl C 2427 Salem Park Drive StreetAddress/PO Box: .... I ........ ......... _ .... ................................................ ................. ......... City/State/Zip Code: ,. W!nston, Salem, Ne 27127 ..................................................................................................................................... Office Phone:....( 36) 717. 9175 .. Mobile Phone:...{336] 406:2323............ Fax #: If the financially responsible party is ,in out-of-state firer, provide information for the in -state registered agent: Nanceof Registered Agent:................................................................................................................................................. StreetAddress/PO Box: ...................................................................................... ................................... ......... ............ City/State/Zip Code: ......................... ..................... ................................... ........................................ OfficePltone:................................................... 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: ............... I .... ....................................................................................................... ......................................... 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. ("Phis form must be signed by the financially, responsible person, if an individual, or their attorney-iu-fact, or if not an individual, by an officer, director, partner, or registered agent with authority to execute instruments for the financially responsible person.) l agree to provide corrected information should there be any change in the information provided herein. Type or Print Name: .... Toby W. Robertson Title or Authority, ,�f Sigoahtre: I..../V r... .... Date:®' F �z�' { � \ ... , a Notary Public of the Cotutty of .....:'.1........... , State of NC do hereby certify that 1 ��..�beJtso� appeared ................................. ......... personally before me this day, and being duly sworn, acknowledged that the above form was executed by Win/her. Witness my handand notarial seal, this........................................................................... day of U:.!.V................................. , 20 Nota€y Public Nat ne: .... /...�.. ..sua(<..?- .............. APRIL R. SUAREZ Notary Public, North Carolina 1' Yadkin County Nota€y Public Signature : ........ .... ...... My ommiss'on EX ices b� My commission expires: ...........W. "•� Z ................ Notat jy Sisal