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Home My WebLink AboutNCC221857_FRO Submitted_20220516City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 MIS1011Mle01 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: West Edge .................................................................................................................................................................................................. Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity: ,5220: 5264, 5284, 5422 Rob inhood Rd ...................................................................................................................................... Latitude: N36° 07' 13.8997" Longitude: .......W80° 22' 05.0691" ..................................................................................... Approximate Date that Land -disturbing Activity will Commence........Aprl1 2022 ............................................................................................... Purpose of Grading: ❑x Commercial ❑x Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots Total Site Acreage: 38.39 ................ aC.............................. GradingMrosion Control Permit Fee. $ 6,. ......298............00................ ❑ Other Acreage to be Disturbed: 2.8...70 aC .................................................... Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: Jack Coupland Email: jcoupland aadamsproproup:com ........ Office Phone:.@431941-4027........ Mobile Phone: (919) 606-4378 Fax # :................................................. Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #:.See attached sheet .. Tax Block #' Tax Lot #: ....................................................................................................... Name: Street Address/PO Box: City/State/Zip Code: ............................................................................................................................................................................................ OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:................................................. Grading Contractor Information: (f known at time ofsubmitting the Erosion Control Planfor revieli) Value of Grading Contract: $................................................... City of WS Contractor ID#:.................................................................. Name of Grading Contractor: ............................................................................. NC License #: ............................................. ---------------- Contractor Contact Person: .................................................................................. Contact Phone:............................................................... Street Address/PO Box: City/State/Zip Code: ........................................................................................................................................................................................... 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: West Edge, LP .................................................................................................................................................. StreetAddressrno sox; 2298 Mount Pleasant St. ................................. City/State/zip Code: .Charleston . , .. SC 29403 ................................................................................................................................ Office Phone:.(843) 941-4027 Mobile Phone Fax # If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Name of RegisteredAgent:PP Tra orp Incorporated Street Address/PO Box:.176 Mine Lake Ct. #100 ...................................................................................................................... City/state/zip Code:.Ra i9. , NC 27615 .................................................................................................................. Office Phone:.(940 251-0650 Mobile Phone Fax #: ......2............................................................................................................................ 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: ................................................................................................................................................................................ Street Address/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 change in the information provided herein. Type or Print Name: .Franklin F . Adams .......................................................................................................................................................... Title or Authority:.Mana�er ................................................................................. ............................::...................... Signature: ................................................................................ Date: ....1/10 .170.,2 2 ...................... I, ...... MA44.t� I l 6ve�on............................................. . a Notary Public of the County of....l..,.!!1,�.�CS'�'o�................. .........................1........................ .... State of ��J�...1..�:`ccli4a........ , do hereby certify that ... rr%rt�t��....F.....rlo a............................ . 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 ..................................................... .5.�........... day of ....... U"� ```�.r'%,..................................... , 20 17m. Notary Public Name:. ��¢(.5 a c p�Qw Notary Public Signature: ��...:................. My commission expires: ....a.w..� ZZ ................................ �p ...... .. 5 .• ' • 4 Q pTAR y , PU B\,\�' Notary Seal 601 N. TRADE STREET, SUITE 200 7101 st i m m e l W w.stim- SALE., m 36.7 www.stimmelpa.com 336.723.1067 West Edge Project #19-057CD Land Owners of Record Parcel Pin# 5896-55-3516 Tax Block #: 4618 Tax Lot #: 144 Name: West Edge, LP Street Address/PO Box: PO Box 20850 City/State/Zip Code: Charleston SC 29413 Office Phone: 843-841-4027 Parcel Pin# 5896-55-6673 Tax Block #: 4618 Tax Lot #: 143 Name: West Edge, LP Street Address/PO Box: PO Box 20850 City/State/Zip Code: Charleston SC 29413 Office Phone: 843-841-4027 Parcel Pin# 5896-55-4015 Tax Block #: 4618 Tax Lot #: 145 Name: West Edge, LP Street Address/PO Box: PO Box 20850 City/State/Zip Code: Charleston SC 29413 Office Phone: 843-841-4027 Parcel Pin# 5896-45-7740 Tax Block #: 4618 Tax Lot #: 20 Name: Robin Hood Baptist Church Street Address/PO Box: 5422 Robinhood RD City/State/Zip Code: Winston-Salem NC 27106 Office Phone: 336-924-4241 LANDSCAPE ARCHITECTURE CIVIL ENGINEERING LAND PLANNING