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Home My WebLink AboutNCC215360_FRO Submitted_20210929STORMWATER/EROSION CONTROL DIVISION 100 East First Street, Suite 328, Winston-Salem, NC 27101 Financial Responsibility/Ownership Form Erosion Control Ordinance No person may initiate any land -disturbing activity exceeding 20,000 square feet for a single-family dwelling or 10,000 square feet for any other purpose, before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Erosion Control Section of the City of Winston-Salem/Forsyth County Inspections Division. Please type or print. If a question is not applicable, please place "N/A" in the blank space. PART A Front Street - Wallburg, LLC Project Name: Wallburg Road - Pump Station Permit # ---------------------------------------------------------------- -------------------------------------------- Location of Land -Disturbing Activity: Wallburg Road, Winston-Salem, NC - -------------- ---------- ----------- --------- ------- ------ --------------------•-----__---------- Latitude 36.039527 Longitude - 8 0. 13 4 7 9 3 Approximate Date to Commence Land -Disturbing Activity: September 2021 Pp g Y�------------------------------------------------------------------------- Purpose of Grading: Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot 9 Residential Single Family Subdivision Total Site Acreage: __8 7 . 9 _ ac Acreage to be Disturbed: 1 .4 5 ac Permit Fee: $ 84 4 ------------------ --------------------------------------------------------- Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Robin Team ________ E-mail address robin@frontstreetcapital_-com ------------------------------------- ----- Telephone __ (3 3 6 )_2 4 3-_2 6 0 0_w Cell # Fax # __________________ Landowner of Record (use blank page to list additional owners): Front Street - Wallburg, LLC Name Owners phone # Name Owners phone # 450 North Patterson Avenue, Suite 300 --------------------------------------------------------------- --------------------------------------------------------------- Street Address/P.O. Box Street Address/P.O. Box Winston-Salem, NC 27101 --------------------------------------------------------------- City/ -------ip Code Tax Code City/State/Zip Code Tax Block #: __ 5621 _________, Tax Lot #: _ 502---_-------_ Zoning: __LI s__________ Zoning Approval: __LI_ s__________. Contractor Information Required Prior to Permit Issuance North Carolina State Law requires that contractors be licensed to perform work valued at $30,000 and higher. Ali contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. Value of Grading Contract City of W-S Contractor's ID # Name of Primary Applicant (Grading Contractor) Contractor's N. C. License Number Street Address/P.O. Box City/State/Zip Code Contact Person for Contractor Contact Person's Daytime Phone Number PART B 1. Person(s) or firms who are financially responsible for this land -disturbing activity (use blank page to list additional persons or firms). Contractors are not considered financially responsible for property not under their ownership. Front Street - Wallburg, LLC --------------------------------------------------------------- --------------------------------------------------------------- Name of Person or Firm Name of Person or Firm 450 North Patterson Avenue, Suite 300 ---W_A------------------------------------------------------- --------------------------------------------------------------- Street Address/P.O. Box Street Address/P.O. Box Winston-Salem, NC 27101 City/State/Zip Code City/State/Zip Code (336)596-9000 ------------------------------------•------------------------------------- Daytime Telephone # Daytime Telephone # 2. If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. --------------------------------------------------------------- --------------------------------------------------------------- Name of the Registered Agent City/State/Zip Code --------------------------------------------------------------- --------------------------------------------------------------- Street Address/FO. Box Daytime Telephone # 3 -if tbe-61tc1AciaUy-respDjLsjhkpNSy is a partnership, give the name ancLAddEtai.tt£ewli-Go=-aj-P=t' ,r-We blank page to list additional partners). --------------------------------------------------------------- Name of the General Partner --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code ------------------------------------ Daytime Telephone # --------------------------------------------------------------- Name of the General Partner --------------------------------------------------------------- Street Address/P.O. Box --------------------------------------------------------------- City/State/Zip Code ------------------------------------- Daytime Telephone # 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 his 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. RobinTea --- - - - / ----------- Manager -------------------------------------- - Type or Pr' t aTitle or Authority -�� LI--------------------- Signature Date ----- , a Notary Public of the County of-------�� o r=-�-----------------------------------' '-- -------------------------- State of North Carolina, do hereby certify that ___ oho -n t a v✓1-------------------------------------------------------------- ----------------- appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this ____ -`-A. day of0 ------------�----------- - - G ---- -- - --- - ---- ---- - ----------------------- 47 _-- Notary ublic My commission expires: Lauren McLaughlin NOTARY PUBLIC Forsyth County North Carolina My Commission Expires November 30, 2025