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Home My WebLink AboutNCC221180_FRO Submitted_20220328STORMWATER/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 "wading 20,000 square feet for a single-Aimily dwelling or 10,000 square feet for any other purpose, before this form and an acceptable erosion and sedimontation vontrol Plan have been completed and approved by the Erasion Control Section of the City of Winston-Salim/Forsyth Count, Inspections Division. please type or print. If a question is not applicable, please place "N/A" in the blank space. Y R Project Name: Miller^s Reserve`rer il{`{ # ...r_...,w..•w,ww.T_.------ rw.ww_w.wwwww_\r.�./l..r_....w.ww.wwww_ ..................... Location of Land -Disturbing Activity: Latitude 36.013763 Off of Ebert Road South of Fraternity Church Road ....................... 1�a----_-=$b,3MP..............,____..................... Approximate Date to Commence Land -Disturbing Activity: Purpose of Grading: 9 Commercial 9 Other (No development proposed) Summer 2020 ............................w_................... ..................... . Residential Multi -family Residential "Single Fancily lot Residential Single Family Subdivision Total Site Acreage; _51.33 w...............Acreago to be Disturbed,, 24.5 Permit Fee: $8,040.00 _..._.._ .... w,.. w,T...-T.-»----n-------_..T_T....wwM..ww4w,d'eTwRc.MaR..ew...... wT»TTwwnr Person. to oontaot should erosion and sediment control Issues arlsc during land-distarbing activity: Scott Wallace esx...�swallace@gokeystone.com Nome ..ww,rr,..r _c..nwT.......... _..._...... E-mtkiladdr.,,..._.. 336-856-0111 Telephone ._ ,_ ..T_ .,.......,T .»,,., . __ . cell # .ww ,..,. ....,...,,....__ Rex #1..,.... ............ .,......,T,...-,.. Landowner of Record (use blank page to list additional owners): Keystone Group, Inc ..,..,..,T.,........w..w..........w....................._ --_ww_....._..w....w.,.----------w-w_------_._ww.._..wwTrw.,w. Namo Q�vnera� phone # Name q�vners phone # 3708 Alliance Drive Strait �A,ddress/P.Q, fox,..... T---------------ww-.----------w Greensboro NC 27407 CityiStatclip Code " ........................................ Tax Block #: w6812 35 w9518w Tax Lot #: ........... ..I�——.. llox........... ....»........ Street AddT_._w_._....w ........................... City/State/Zip Code Zoning: RS_9 PRD,_T__ Zoning Apnroval?019.05/2019094 Contractor Information Renuire(I Prior to Permit Issuance ftr& Carolina more Law requires t/tat contractors be licensed jo perfirrm work valued at $30,000 ira t lilgher. All cal:(raclors must have a 001 of `Winston-Salem c on(ractor+r 10, aeallabla at no cast through lira City Is Revenue offlee. $ sty E/ 1 000. �i :� +� QV v) 9 value of Grading Contract Namo. of Primary AppliQaut (Grading Con08000 Stroc.t AddresslP.A, Box City of - Co tr r` etgr.•'s ll<?- �__ E� Contractor's N, CC, Liconse Number Contact arson�r ContmvtorCantmvtor ";;i0-Gaf) I - 8kgoo :ity/StatOzip Code Contact Person's Dayttmo phone Number PART— 1. Person(s) or firms who are financial 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, Keystone Group, Inc Name of PGraon ar Firm 3708 Alliance Drive Greensboro/NC/27407 City/Statelzip Cade ------------- _---- n.nw.. 336-856-0111 Daytime Telephone # .................... w... w. w rrw.._-._ _.------. Name of Person or Firm w..«........................... Street Address/F.Q. Box....... ..................................................... ... Cade.............w...._-_....._.....n...... City.&tat. Daytime Telephone #,....»...,w.w. 2. if the financially responsible party is an out of -state resident, give the name and street address of the registered in -state agent. Nam + e of w_.we.....e................................ the+Registered Agent !.>wwl..rtw.w...... e.eeeewe....ww.ewwweaw.»ew,-e..we+w.wrw..... nnwwwww Street Address/P,O, Box www..r_n..wewwwww-n__w.w-.,....n,n..ww•.ww_.,..w-.nwww------- ---_......... city/Statefzip Code . I— ...,e.Talephane# «w.wn_wn_www._ww»l. w-n----n-- 1wlirl<bifXutil,ttci4.UM§SlAn*&. early is a partnership, give the name aatcia dt�ss�I c S3��wl? �f,(itse blank page, to list additional partners), s....... 0................w w«. ....... Name of the General Partner .......... Street AddreWP.Q. Box City/Stet@fwlip Code-------------. ------_--- .-----..--_--w Daytime Telephone # Name of the GeneralPartner w-_w_n__wwwn wnn,__nn,w, ,,n_._ Street AddrtsslP,Q.wI»ax_n...- .,.... CitylState/Zip Cade ..................................... 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.) l agree to provide corrected information should there be, any change in the information provided herein, president W.Scott Wallace w..r.r.,_-----,w--------------------------------------.------!_-_...........w«.._.-----------w . '�ypa or FNawR,ww.,wwRww------ --wnnw -w Title or Authority w • _ ^ �� f.....w•,.w........w wwR,..ww.l.._w ....... Signature )i?awte 'r ( oe l 1,t e a Notary Public of the. County of �v I- � %i 1�., .. w... _._.-n.w.,_. w_w __«__..-. .w.w..ww ewe � State of North Carolina, do hereby certify that ..«.nW =. Sw:-1 r k,/Att-, i .-n..wwwwwwww....w.w.....w.«._w_w_,--n+_w,_,<._v,_w-_n__nn,w-.n.w__nwwn_ 1 appeared personally before me this day and boinggduly sworn acknowledged that the above form was executed by him. Witness my hand. aAd notarial seal, this w. 4^ww. waay of _ 19 �'4e!—r ...... _w' 20 wwwww .... 2-Z... - - My commission expires;..2 2. ................w......_......_.... �-- �..w_ ubl nWALLACE PUBLIC OUNTY, NC —�