NCC223176_FRO Submitted_20220909

City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101
Wfn.51igt1S" Mailing: PO Box 2511, Winston-Salem, NC 27102
t
Financial Responsibility/Ownership Form
No person may initiate any land -disturbing activity exceeding 20.000 square reei 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 NW6 been submitted, reviewed, and approved by the City of Winston-Salem Erasion
Control Division and a Grading/Erosion Control Permit has been issued. Please type or punt. Please place "N/A" in the blank space if
not applicable.
Part A
Project Namn. Metropolitan Village
Gaiding,Trosion Control Penttrt tt:EN2200155 ..... ...... I. ...... .
.
Ilocatiort of LAiiid-disturbing Activity: ............................................ 410Woodland Avenue tNinsto - .... ..........
n-Salem, NC 27107
Latitude:. §:099 .... .....................„..., ...............................
.......... Longitude: ,.gp. 232..............................
Al�proxirttate hate that I 2 ,.................. .....................
�° nd-disturbingActivity will Commence• August 202
Punc�asc of Grading:
..»...................................................................<....,......................,.........
Q Contniercial XResident.ial Mulli•fitnily
a Residential Single-family Lotn,ots
Total Site Acreage: 59�........................................
Gradin„f rosion Control Permit 1,ec: 5 1,652.00
0 Residential Single-family Subdivision
0 Other
Acreage to be Disturl d: J:$6........................>............,...........
Person tea e.ontact should Erosiori Control related issues arise during land -disturbing activities:
Nalne: ,,Andrew 0rogdon............... and bro don ttbe
........................... Email...................
......................
00ice Phone: ... (T94) 461-2r�66 ... Mobile Plione:.(794 .`A-7604 Fax 4: NfA
................................................
Landoki ner of Record: (tine hluttkpage° to list (zrlclitiratrit1 csti°nc't:� rJ'tac=ec%tlt
11�4
..,C:,.............................................., 'fax Block 4:....... 999$ �02
.............. TLx l..oi #.
N:
l*0 Ii,),:..I.201 Edtntards itAiil Rpad,.Suitt;'3t10...................................................................................................
S= .. ': p f-'/tit ialeigh:... 27607 ......................................................................................................................................
(919-582-3100) NtA .......................
....................- Mobile llhotrc:..........•...,. . FaxN/A
-":............................................
Gt :rli.rig t."ontr•acfor inforill alion: (it ktaonrrt at tilne qi ,suhtliittitk the L'rosioi: t.'Urtttol Plait fi r tc=viex)
i < <i t.r t /> t,r...� [ .,...._......, N/ ...................,...... City oI WS Contractor II} t::....,........,.......... �'a,........,....,,,..,,.,.... ,..,.
' ntra
"� (si C Tracts ................. N/A t�'
"ti
......,............... .................. �. l�icc.n`t. -r.,...............,...........,pp............,.,,.,... ............
N/A
............... ................... ,.................. ............... Contact Phone: NfA
...../`...........................
.........
.........
....................
...,..,...........................,,........,.:................., ........,..,....
N/A

I`et-soil(s) of, III -ills 1Vilra a11`4' filialiclrilly lilespollsible fall fills IAIntl-disturbing art�ivlty: fim blank page to tint additit`ittsl
piyrsori(s) or brit if amdedl *"Contractors are not considered thturicialiy responsible for Property not under tlacirowncrship"'
� i qrt Atlantic C7evelo went ��artner
Manic of Person n or Film ,�!,,,,,,,,,,,,, ,. ,�?. ,,.,,...,,....,,...........,........,..,....,...,..,.,,,.......,,,..,,..,,.,,.,,.. ,
Strc:c:t Address/lid Eiox:.,p1tl4N!bridg....................................................................... ................
�.,
City/Stale/zip t' ctc:: iCh Matt , N 2 2i3 ..... ............ ...,.,,.
Office 10llot1e: (7qj). §, -20fi ............. Mobile Phone, .,.......,.... ,,.NII?.,,,,.., t'ax P;....... , ItiJIA .... ..
II' tllc` financially responsible party is an out-of=state firm, provide. illti)rrrlation ft►1` the in•°viate registered agent:
Nameo1'RogislerrdAlwrtt:... W6............................. „,.,........,........,.,,.........., ..,,..,,............., ...................
StreetAddruss/1'O fttrx:,,iV,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
C'itylsfatcllip C'ticic: ,.................................................................................
Nli�► Mobile i'hane; N/A ...................... Flax #:.................. NIA........,.,,..........,
Utlice Phone: .............. ......., ..
If the lilialieltrlty rGi+parnvitylcs party is it pa rtnerslrip, provide infi►rrarutiotl tin't:alrfl (seneaall Partner:
(use blank page to list addifiorull partuui;w if'nr!�'alctl)
Name f)l` 1{ertristetvd Agenf.- ...... .................. ............ .... .
;trc:ftt tl.ciclrc!tis/I'O Ilox:—NIA- .................... ...... ,...,....,,,..,,........,,...,..,.....,,,..,..,.,.,,,.,...,,....,.......,...,......,.,....,.,.,..,.....,...,...,..,..,..., ,
t'ity/Staiclrrill Cudt:; ,..(V/a!;.............................................. ........... ................................................,...,.,.,..,,..,..,
N/At iix t1:......... ......... t�1........................
N1�1 tvtctt�itc I'bcuic: .................•�, ..
a.►€lice i'llotio:....,,,,.,, ..........................
ld
1 ht atlt��`{° inlilrrtulfi{ili i,, nve and (All is, rorm
recl to thO hest }}f u�Y'k{livi lunl, oilolylvdge rrihctir latl{ltnr,.y�in I u;t, tar Itlnt t rur�luY�hltiiduail, hy�iat officer.
111+.1 i I,t siipnt;d by MC tinallc�ially roltonsiblc Ivr.,t!n, ri at rn
(IlIct:t{Ir. Iml-fllt'r, {,r'rcj' ;tt�ret.i 111{�nf will, lulfhlnity 14) e b"we ilntionatlr{lv�iilt�dfh'�rs�tttrlt`�inily rii!+it<>rtsit�lc pera{In.► 1 rtl;,r�{; icl prawn{ �-
c.,,rrt'e'tc'ri infor,uniinn �alu,lilJ ilivic ln, arty challgo Ill t
s ir) aNtrinr'.Y ►'td,lit of ib,
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HIH-WS, LLC
1201 Edwards Mill Rd, Suite 300
Raleigh, NC 27607
11 August 17, 2022
The City of Winston-Salem
101 S. Main Street
Winston-Salem, NC 27011
RE: Metropolitan Village - Stormwater Management
Mr. David Evans,
Please consider this our formal approval for Liberty Atlantic Development Partners in partnership with United
Metropolitan Missionary Baptist Church to begin development and construction activities on the properties
located at 918 East Fourth Street;1010 East Fourth Street; 911 East Fourth Street; and 310 Woodland
Avenue.
Best Regards,
Jaron M. Norman, Member
HH1-WS, LLC
T -ruv unl 1gING I. WI.NSTON-SALEM (FIIiI-WS)

G.S. § 1 OB41 NOTARIAL CER17FICAT E FOR
ACKNOWLEDGMENT
�'- ' County, North Carolina
I certify that the following person(s) personally appeared before me this day, each
acknowledging to tree that he or she signed the foregoing document:
Date: 09 - 19 ` 202 2
(Official Sea))
Name(s) of principals)
QUIoial Signature afNotary
/ A ' 1�Dgdd Notary Public
Notary's printed or typed name
My commission expires: !`R -©9. 402-,�,,
OP'nONA L,
This certificate is attached to a - signed by �fr p ,tip y+•? Nc�.� ��.,9 V
7f&TyPeofZkacument Name srfhincipal signeTw
on () �'`f.�s 1 �Land includes_ C N c_ pa. es
Date #7 ofpag"

w09 estRiver FlrTH THIRD BANK
W
CONSTRUCTION
8349•P Arrowri'p Blvd 66.731531
Charlotte, NC X273
980,938.8471
90
trTC- EtJ AAW ;;F�
PAY t�-Lr—,V4W 7—H6\JX1A'-J0 7�pm-
TO THE DATE
ORDER C)Fc Y 0 F 19A
(it) 3, 33
13
AMOUNT
t_ -:— 8
9 ?M
AUTHORaED SIGI-JArUnr

WEST RIVER CONSTRUCTION ® CHARLOTTE, NO 28273
WEST ROVER CONSTRUCTION CHARLOTTE, NO 28273
001334
001334
CA1625047001 01