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Home My WebLink AboutNCC221213_FRO Submitted_20220329UV City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 W1ns1nnM1r.in 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 "NIA" in the blank space if not applicable. Part A PrajectName;,Novant Health Critical Care Tower Early Release Package ........................................... ...................I......I... ....... Grading/Erosion Control Permit #:.E N220003................................................................................................................................. Location of Land -disturbing Activity: 3333 Silas Creek Pkwv,. Winston-Salem, NC 27103 ..... ......... ......... Latitude: 36:675...86......................................................... Longitude:.r80.298525...........:................................................ Approximate Date that Land -disturbing Activity will Commence:.Mar.c.h 2022 Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑x Other Total Site Acreage 67.48 ac Grading/Erosion Control Permit Fee: S ,450 Acreage to be Disturbed: 4. 0 aC Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: Shane Rowland .................................................. Email: shane:rowland[�7a .e..row.l.an.d@j.rvan.noy..com ..................................................... 336-448-1950 336-316-8549 336-283-9651 OfficePhone:...... ............................................. Mobile Phone:....................,................................. Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #: 68 4.-68-8340........................................... Tax Block #: 3806 6 U I ... Tax Lot #: 950........................ .......I...I.. I..... Name:.NoVant,Health Inc. ................................................................................................................................................................ Street Address/PO Box: 190 Kirnel Park Dr #125 ........................................................................................................................................................................ City/State/Zip Code, Vlliasto-.Salem,..NC 271103.................................................................................................................. .. .................. Office Phone: rr335j 277-8681 .................................. Mobile Phone:.................................,....,............... Fax #:................................................. Grading Contractor Information: (rf known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: S................................................... City of WS Contractor ID#:.................................................................. Nameof Grading Contractor.............................................................................. NC License #: ........... .................................................... Contractor Contact Person: .................................................................................. Contact Phone:................ StreetAddress/PO Box: ..................................................................................................................................................................................... City/State/Zip Code: ........................................................................................................................................................... I ............................... 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: No.vant Health Inc. Street Address/PO Box: . g0 Kimel Park ❑r #125 CitylStatelZip Code: Vyinston-Salem, NC 27103 Office Phone:.1g361 277-8581 .. Mobile Phone: . Fax #:.................................................................................................. 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 shMId hAn�yj�chhaange in the information_ prrovided herein. Type or Print Name:...... M �..f(f�' -............................................................................. le Title or Authority:....... ......V,�....f. Lr............................................................................ 3 Signature: ..................,......:.....,............................................................................. Date:.. r 3.. P ............... i, .5h"� ..M. ....._AbAe ....................................... . a Notary Public of the County of.... lff. 5 ZJI ................. State of 1A ............ WAif4do hereby certify that ......+...Y awu..... 'tK'�................ , appeared personally before me this day, and being duly sworn, acknowledged that the above form was exe`c'uted by himlher. Witness my hand and notarial seal, this .............. ltl. ..... aJ ........................ day of ...........Y� a CV............................... , 20,5M.. `'4,'�tpHl t e � r H hrq••••i N0N s Notary Public Name: W%W hi?n....4.1_j6V1C...... � R �� Notary Public Signature ..... My commission expires: A ...... ��.....t?:G41.4.7........ ��,� -��' � ,,,�°•7Ht�C�Ok)