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Home My WebLink AboutNCC222717_FRO Submitted_20220811City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WInsIMINEM Mailing: PO Box 2511, Winston-Salcm. 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 Pennit has been issued. Please type or print. Please place "N/A" in the blank space if not applicable. Part A Project Name: Weaver Fertilizer .......................................................................................................................... Grading/Erosion Control Permit #:................... ........................................................................................................................................_..... Location ofLand-disturbing Activity:..4440 N. Cherry......Street..,..Winston.....Salem.,..NC............................................... .............................................................. Latitude:..36.149507 . Longitude.....'80.:264972 ------ Approximate Date that Land -disturbing Activity will Commence: ........ N/A .. Fire ...............response/cleanup............................................................... --..--. Purpose of Grading: N Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 8.46 .. Acreage to be Disturbed: 6.7 Grading/Erosion Control Permit Fee: $ $1.793: 00 Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: . -Adam Parrish Email: AParrish@mfifert.com ............................................................................................................................ Office Phone: NIA........ Mobile Phone:.,+19197208469 Fax #: N/A ...................... ............................................................................ Landowner of Record: (use blankpage to list additional owners ifneeded) .5827-65-4874 ... Tax Block # NIA NIA ParcelPIN #:. ..................................................................................... Tax Lot #:................................... Name: ..Weaver Fertilizer Inc. ............................................................................................................................................................................................... Street Address/PO Box:..4440 N. . Cherry . .. .. Street ....................................................................................................... ...... City/State/Zip Code:. Winston Salem...NC............................................................................................................................................ (336) 661-1495 Office Phone: ............................................ Mobile Phone: ....N . �...A ........................................... Fax #:.TA ........................................ Grading Contractor Information: (ifknown at time ofsubmitting the Erosion Control Plan for review) Value of Grading Contract: $ N/A .......................................... 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*** Weaver Fertilizer Inc. Nameof Person or Firm: ..... . I ............................... .................... ....................................................................................... Street Address/PO Box:..4440 N CherryStreet .............. '. ................. City/State/Zip Code- ..Winston..S...alem.,..NC. ............................................................................................................... Office Phone: 336-661-1495...............Mobile Phone: ................................. Fax #:................................ ................. ..................... If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Age1rt:..N/A.........................................................................................................................•-.--...... Street Address/PO Box: ...................... City/State/Zip Code: Office Phone: ................................................... 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) Name of Registered Agent N/A 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 attomey-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. MICNtkEt^ T. C?�NC& Typeor Print Name:.......................................................................................................................................................... Title or A cinty:. �............°.& KA N!iG�R— .............................................................................................................................. .. . Signature:.................................................................................................................................. Date: ............................................ G rl.�nln� r�l 1S-• QS 110Y1Dve.r :.............................. . .............. . a Notary Pubhc of the County of ..................................................... ��tae 1 .T S �� State of Vfri.f.a.f.0, do hereby certify that ............................................... . r ............. , appeared .................... personally before me this day, and being duly sworn, acknowledged that the abovp form was executed by him/her. Witness my hh , hand and notarial seal, this............................................................. day of ..... r 2................................................... , bc(19' CHEIN Notary Public Name: Ch.... !A,.... J................ ........ COMMO OnT�Apy PUS i�blAg MY COMMISSION l IgEs NjAY 311 2026 NotarS� Public Signature: .............................��........... ......... COMMISSION # .._...,_,,,,_ 7781939 My commission expires: ............................................................... Notary Seal