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Home My WebLink AboutNCC223479_FRO Submitted_20221011City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salcm, NC 27101 R1119 0UM 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/F,rosion Control Pen -nit has been issued. Please type or print. Please place "N/A" in the blank space if not applicable. Part A Walkertown Self -Storage ProjectName: ....................................................................................................................................................................................................... Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity:... 5030 Old Wa.lkerto..w.. n Road . .. , Wi.nston-Sale..m, ....NC..27105.................................................... ............................................................ Latitude:..... 36.1578N................................................................. 80.2021 W Longitude:............................................................................................ Approximate Date that Land -disturbing Activity will Commence: ...... ......October..2022 .............................................................................................. Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots Total Site Acreage: .... 4.20 ................... Grading/Erosion Control Permit Fee: $ 1:046.0.0 ................... ❑ Other Acreage to be Disturbed: .....276..... ................................................ Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: .,,Cameron Hoover ..... Email:...... camhoover1l@gmail.com ............................................................................................................................................................ OfficePhone: ................................................... Mobile Phone: .... 717-682.5595........................ Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) 6847-58-1750 ParcelPIN#:..................................................................I............... Tax Block #:.................................. Tax Lot #:................................... Name:...... Walkertown Self Storage, LLC ................................................................................................................................................................................................ Street Address/PO Box: , 3028 Spooky Nook Rd ............................................................................................................................................................ City/State/Zip Code:..Manheim: PR 17545................................................................................................................................................... Office Phone .................. Mobile Phone:..717-682-5595 .......... Fax #: .................................. ........................................................................ Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) Valueof Grading Contract: $................................................... City of WS Contractor ID#:.................................................................. Nameof Grading Contractor: ............................................................................. NC License#:................................................................ ContractorContact Person: .................................................................................. Contact Phone:............................................................... StreetAddress/P0 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: Walkertown Self Storage; LLC.................................................................................................... Street Address/PO Box.... . 3028 S.pooky .. Nook Rd ............................................................................................................................................... City/State/Zip Code Manheim, P..17545 ........................................................................................................................................................... Office Phone: ......................... Mobile Phone: 717-68...5595 ..... Fax 4: .......................... .......................................................................... If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Name of Registered Agent:.,Litt.ewood Law, PLLC ............................................................................................................................. Street Address/PO Box:.., 4208 Six Forks Rd, Suite 1000 ................................................................................................................................... City/State/Zip Code Raleigh, N..27609 ............................................................................................................................................................ Office Phone:... 919.518.9508 . 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 attomcy-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 infonnation provided herein. Type or Print Name: Lar H U&J ........................................................................................................................................................ Title or Authority ./�/vu°I............................................... Signature:......................................................................................................... Date:.................................................... UA A ��, vk /-,ram I. .....................%.................................................................... , a Notary Public of the County of ...................................................` State of ....... !..�.................................... . do hereby certify that ..... - A00!"j.........A :.vd)z'............... , 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 `� ....... day of OC7-41 ' ZZ ..................................................................................................................................... , 20 ........... Notary Public Name: ..........4� ................ ... �................................... Notary Public Signature:.............................................................. Mycommission expires: .............. la/ .7./ .�' s............ ................................... Commonwealth of Pennsylvania - Notary Seal Chad M. Boyer, Notary Public Lancaster County My commission expires October 17. 2025 Commission number 1015555 Notary Seal