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Home My WebLink AboutNCC223561_FRO Submitted_20221019City of Winston-Salem Field Operations Department ( Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WlasloUSHlem 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: ......Express Tire - University Parkway .................................................................................................................................................................................. Grading/Erosion Control Permit#:.................................................................................................................................................................. 6137 University Parkway Locationof Land -disturbing Activity: ............................................................................................................................................................. Latitude:.....36:194230 .. Longitude: ............................................................................................................................ Approximate Date that Land -disturbing Activity will Commence: ....JUIy 2022 ........................................................................................................ Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 1 '90 ... Acreage to be Disturbed: .......................................................................................................... Grading/Erosion Control Permit Fee: $ ...844...................... Person to contact should Erosion Control related issues arise during land -disturbing activities: Gary Howorka ......... Email 9howorka@expressoil.com Name: .................................................................................................................................................................................. Office Phone:....336.377.2690 Mobile Phone: ,,,,336:377.2690 ................. ............................. Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) 6829:22:9032 & 6829-22-8156 Parcel PIN #:..... ........................................................... Tax Block #:.................................. Tax Lot #:...................... Name:. ..�...... � A A. .............................................................................................................................................. StreetAddress/PO Box:tZ:i.................................................................................................................................. City/State/Zip Code:�,ts.w.�.k.r,'n..... ........ ........................................................................................... ..................................... Mobile Phone:. Office Phone: ............. ��.,`' �..�..�.�....��....L?.......... Fax #:................................................. Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review) T.B.D. Value of Grading Contract: $................................................... City of WS Contractor ID #:.................................................................. Nameof Grading Contractor: ............................................................................. NC License#:................................................................ Contractor Contact Person: .................................................................................. Contact Phone:............................................................... StreetAddress/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: .DR.A.....)Av �.,..... UL �.........................................................................................I Street Address/PO Box:L,�^v,11 L Sk1... 1.4.................................... City/State/Zip Code: !!0 !i?....?.�e`'�.,.....1.L... Z �.I.Q.'.......... Office Phone: ................................................... Mobile Phone: .. .. .. 3....i. Q Fax# :................................................. If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Name of Registered Agent: Street Address/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 shou there be any c an i information provided herein. Typeor Print Name: .. /� ....... G,............................................................................................ TitleorAutho ...G.../........ .... ............................................................................................................... 2 Sicnatur ....................................................... Date: I, .........QY ... ..................................... . a Notary Public of the County of .--hy"St,................................... State of . .�4l4 (�!!«. , do hereby certify that ..1 e ... . ............. k!.................................... , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my handand notarial seal, this ..................................................................... day of ��............................................ , 20 Z. ALDR y Notary Public Name: ....... ..... .........�...!K 2...t...... 0) Notary Public Signatu .. .......... P z �7 sT �; My commission expires: ...�4..7.......... ,''•.,,0ftES1 eal °#,,ao�oouae`��