NCC233018_FRO Submitted_20231009

_AP City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E. First Street,Suite 328,Winston-Salem,NC 27101
i4�llSlfllltiilltlll 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 Name:..8.HWEf..GJOV.erclalQ..A.S..Ci
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: ..'r Rol. !G� ��..t4►.V. ,..M.I�I C..ti�XC.�G�. t..M�C�l.Ccs I.Cr q. L.�J.Y.S�
Latitude: ..r3.Q.,Q 99 Longitude: ..$Q.,2.7.2.1
Approximate Date that Land-disturbing Activity will Commence: October 2023
Purpose of Grading:
lgl Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑Other
Total Site Acreage: 7.48 ac Acreage to be Disturbed: 7.Q1 G
Grading/Erosion Control Permit Fee: S
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Glenn Gangitano Email: ..99.O.O9it C .W..ak0ha .ittlAu
Office Phone: .3 ..7.W7.2644 Mobile Phone: 743- 49-Q990 Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN #. See next page Tax Block#: Tax Lot#:
Name: NC Baptist Hospital
Street Address/PO Box: Medical Center Blvd
City/State/Zip Code: Winston Salem, NC 27157
Office Phone: Mobile Phone: Fax#:
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: S City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/PO Box:
City/State/Zip Code:

6825-33-7647 NC Baptist Hospital
6825-33-7909 NC Baptist Hospital
6825-33-8823 NC Baptist Hospital
6825-33-8919 Med Found of BGSM & NCBH Inc
6825-33-9688 NC Baptist Hospitals Inc
6825-33-9964 NC Baptist Hospital
6825-34-9043 Med Found of BGSM & NCBH Inc
6825-43-0822 Wake Forest University Health Sciences
6825-43-0872 NC Baptist Hospital
6825-43-0969 NC Baptist Hospital
6825-43-2618 Wake Forest University Health Sciences
6825-43-2802 NC Baptist Hospital
6825-43-2956 Med Found of BGSM & NCBH Inc
6825-43-3906 NC Baptist Hospitals Inc
6825-44-1030 NC Baptist Hospital
6825-44-1081 NC Baptist Hospital
6825-44-5008 WFU Health Sciences
6825-43-8944 WFU Health Sciences/NCBH Inc

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: ..tciurn.HQalfh.W?k.?.F.QC.4'.S.t.faapii$t
Street Address/PO Box: Medical Center Blvd
City/State/Zip Code: Winston Salem, NC 27157
Office Phone: [phone] 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:
Office Phone: Mobile Phone: Fax#:
lithe 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:
Street Address/PO Box:
City/State/Zip Code:
Office Phone: 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: Kevin High
Title or Authority: President- Atrium . -alth Wake Forest Baptist
Signature: Date:
---)- -. 8"/ 2o23
I, 1i-Q`- _ ` , \OLOt t , a Notary Public of the County of a V
State of N C do hereby certify that........ erv.La...i-ki�I.LV.1. , 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 S fk day of ......A.(Aysk- ,20.4?�...b
Notary Public Name: IYaGItA l��t ":.• TRACT M MAGINNIS
y�/f .A, Notary Public
Notary Public Signature: dC. 1' ? / (�� North Carolina
�( 1 —� Davie County
My commission expires: "'� Notary Seal 4

;% Atrium Health Administration
Medical Center Blvd.
Wake Forest Baptist Winston-Salem, NC 27157
WakeHealth.edu
August 8, 2023
City of Winston-Salem
Erosion Control Inspections
100 East First Street
Winston-Salem, NC 27101
Attn: Matthew Osborne
Re: Permission to Conduct Land Disturbing Activities at
PIN(s) 6825-33-7647, 6825-33-7909, 6825-33-8823, 6825-33-9964, 6825-43-0872, 6825-43-0969, 6825-44-1030,
6825-44-1081, 6825-43-2802, 6825-33-9688, 6825-43-3906
NC Baptist Hospital/NC Baptist Hospitals Inc
Winston-Salem, NC
Dear Mr. Osborne,
As the landowner of the above referenced property, I authorize Atrium Health Wake Forest Baptist to pursue approval of
an erosion and sediment control plan for the AHWFB Cloverdale ASC project located in Winston-Salem, NC. I also grant
permission for Atrium Health Wake Forest Baptist to perform land disturbing activities on this property upon City of
Winston-Salem/Forsyth County approval of the erosion and sedimentation control plan.
Please contact - at 336-7 6-6211 or [e-mail] with any questions.
Sincerely,
Kevi High, MD, MS
President, Atrium Health Wake Forest Baptist
SIGNATURE & NOTARIZATION

G.S. § 10B-41 NOTARIAL CERTIFICATE FOR
ACKNOWLEDGMENT
Davie County,North Carolina
I certify that the following person(s) personally appeared before me this day, each
acknowledging to me that he or she signed the foregoing document:
Kevin High
Name(s) of principal(s)
Date:August 8, 2023
(Officialj4 Seal) U ' l c t ' i
Official Signature of Nota�
lJ TRACI M MAGINNIS Traci M. Maginnis<�. 9 ,Notary Public
tw � Notary Public , .._....
k(' J � ` Notary s printed or typed name
North Carolina
Davie County August 4, 2025
My commission expires: g
OPTIONAL
This certificate is attached to a Letter to City of Winston-Salem ,signed by Kevin High
Title/Type of Document Name of Principal Signer(s)
on August 8, 2023 ,and includes 1 pages.
Date #of pages

400 Atrium Health Administration
Medical Center Blvd.
Wake Forest Baptist Winston-Salem, NC 27157
WakeHealth.edu
August 8, 2023
City of Winston-Salem
Erosion Control Inspections
100 East First Street
Winston-Salem, NC 27101
Attn: Matthew Osborne
Re: Permission to Conduct Land Disturbing Activities at
PIN(s)6825-43-0822, 6825-43-2618, 6825-44-5008, 6825-43-8944
Wake Forest University Health Sciences /WFU Health Sciences
Winston-Salem, NC
Dear Mr. Osborne,
As the landowner of the above referenced property, I authorize Atrium Health Wake Forest Baptist to pursue approval of
an erosion and sediment control plan for the AHWFB Cloverdale ASC project located in Winston-Salem, NC. I also grant
permission for Atrium Health Wake Forest Baptist to perform land disturbing activities on this property upon City of
Winston-Salem/ Fors I County approval of the erosion and sedimentation control plan.
Please contact r- at 336 716-6211 or khigh(c.wakehealth.edu with any questions.
Sincerely,
Kevin igh, MD, MS
President, Atrium Health Wake Forest Baptist
SIGNATURE & NOTARIZATION

G.S. § 10B-41 NOTARIAL CERTIFICATE FOR
ACKNOWLEDGMENT
Davie County,North Carolina
I certify that the following person(s) personally appeared before me this day,each
acknowledging to me that he or she signed the foregoing document:
Kevin High
Nmne(s) ofprincipal(s)
Date:August 8, 2023
(Official Seal) 011&1 ,111.a64/(A ,
Official Signature of Notar
Traci M. Maginnis ,Notary Public
TRACI M MAGINNIS Notary'sort ed name
Notary Public Y printedYp
1 RrK
5.1rOt North Carolina
August 4, 2025
Davie County My commission expires: 9
OPTIONAL
This certificate is attached to a Letter to City of Winston-Salem ,signed by Kevin High
Title/Type of Document Name of Principal Signer(s)
on August 8, 2023 ,and includes I pages.
Dale #of pages

AtriumHealth
Administration
Medical Center Blvd.
Wake Forest Baptist Winston-Salem, NC 27157
WakeHealth.edu
August 8, 2023
City of Winston-Salem
Erosion Control Inspections
100 East First Street
Winston-Salem, NC 27101
Attn: Matthew Osborne
Re: Permission to Conduct Land Disturbing Activities at
PIN(s)6825-33-8919, 6825-34-9043, 6825-43-2956
Med Found of BGSM & NCBH Inc
Winston-Salem, NC
Dear Mr. Osborne,
As the landowner of the above referenced property, I authorize Atrium Health Wake Forest Baptist to pursue approval of
an erosion and sediment control plan for the AHWFB Cloverdale ASC project located in Winston-Salem, NC. I also grant
permission for Atrium Health Wake Forest Baptist to perform land disturbing activities on this property upon City of
Winston-Salem/ Forsyth County approval of the erosion and sedimentation control plan.
Please contact ► - ;6-716-6211 or [e-mail] with any questions.
Sincerely,
Kevin High, MD, MS
President, Atrium Health Wake Forest Baptist
SIGNATURE & NOTARIZATION

G.S. § 10B-41 NOTARIAL CERTIFICATE FOR
ACKNOWLEDGMENT
Davie County,North Carolina
[ certify that the following person(s)personally appeared before me this day, each
acknowledging to me that he or she signed the foregoing document:
Kevin High
Name(s) ofprincipal(s)
Date:August 8, 2023
(Official Seal) CA/6 IT ��Z
Official Signature of No rt y
TRACI M MAGINNIS
,ry, Notary Public Traci M. Maginnis ,Notary Public
, � North Carolina Notary'sprinted or typed name
I Y yp
Davie County
My commission expires: August 4, 2025
OPTIONAL
This certificate is attached to a Letter to City of Winston-Salem ,signed by Kevin Nigh
Title/Type of Document Name of Principal Signer(s)
on August 8, 2023 ,and includes 1 pages.
Date #of pages