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Home My WebLink AboutNCC220755_FRO Submitted_20220215UP City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 Wnsloll$alem 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 Pro .ect Name:...Hillcrest .Townhomes.....-..Phase....1 ..&..2 .................................................................................................................................................................. Grading/Erosion Control Permit #: .................................................................................................................................................................. Location of Land -disturbing Activity: ... 1725 Eagle Creek Drive: Winston Salem NC, 27101 Latitude:...M;054501 .. Longitude:...-80;323702 .................... Approximate Date that Land -disturbing Activity will Commence:.......... �. r°� i.. {.-............................................................. Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision N Residential Single-family Lot/Lots ❑ Other Total Site Acreage: ...9..36.. ................................................ Grading/Erosion Control Permit Fee: $.................................. Acreage to be Disturbed: ....5:56..................................................... Person to contact should Erosion Control related issues arise during land -disturbing activities: Name:..siman Burgess Email: sburessa trilag�ic.com ................................. .............. Office Phone: Mobile Phone 910-690-4217 Fax #: Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #:.. 6 04-81.: 9374 .. Tax Block #• 3900 Tax Lot #:.405C.................... Name: ... TIC 1 Hillcre.st..LLC................................................................................................................................................................................... Street Address/PO Box: .102 W 3rd Street, Suite 725 City/State/Zip Coddle:.... inston Salem, NC, 27101 ................ ] Office Phone: ... I I a ..................................... Mobile Phone: 910-690-4217 Fax #: ...... ................ 0-- 1........ Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $ . �I `5.... .....,...I.... City of lWSr-_Contractor ID #: ........... ......................................... Name of Grading Contractor:.!(..`. (�lm..... �:...... •�?'�NC License #:....... tQ�...........�....�................. Contractor Contact Person:....V Ja �k.�Contact Phone:. Q,. k-7.... Street Address/PO Box: �.�.�4..g....... 1%�qu(nQ& ......................... G.....••-----................................................................. �j City/State/Zip Code:..Y...R �� .. � �+-� � �� .?......... �-•....................................................................................... 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*** y Name of Person or Firm ...... I .......1..... t �...1L. L Street Address/PO Box: .... 1.©....... r.... r...:....................................................... ........ City/State/Zip Code: lic - .ct.t 2Wl�lC l ......� F c.................................. Mobile Phone:........ L� `tF�� . Fax #: .....Z . j ....................... Office Phone: .... .�... ..... ..... If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: .............................................................................................................................................. StreetAddress/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:..................................-----...............................................................-•----..............................---•--................................ 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.) I agree to provide corrected information should there be any changeinthe information provided herein. Typeor Print Name:......_............................................................................................_ YN Title or Authority: ........................ ........r.............................................. ................ _.._........._.............................._.... . Date.........2.. .� _........... Signature:...........�'�..... :....... � -•- -.....................---••-•--•-�........................... 1....... ........ 1'fF �L� ' . a Notary Public of the County of ...� v 1 I................:�...........................i...Q' , , State of .....t'.�`.. �?4......�'L .. , do hereby certify that ��'.s r�-- ,appeared '. y fy .............. ......... personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my IAI hand and notarial seal, this. .................... day of ......'' .� �� Zvi .......................................................................... , 20 ........... E BROYHILL JR Notary Public Name: .... � "!�.".:.�.......:...�..:� �'��'..`.��.��2' RY PUBLIC D COUNTY, NCNotary Public Signature: .... !l�ll .. :...... �............. ..:. ion Expires 5-2-2025 My commission expires: .........: .`?'................................ Notary Seal