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Home My WebLink AboutNCC223955_FRO Submitted_20221128City of Winston-Salem Field Operations Department I Erosion Control Division lee I'll' Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 MIS1011S01Clll Mailing: PO Box 2511, Winston-Salem, NC 27102 Financial ResponsibilitylOwnership 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 "NIA" in the blank space if not applicable. Part A ProjectName: .... 4th AQ0. Green,Apartments................................................................................................................................................. Grading/Erosion Control Permit #:..... .......................................................................................................................................... Location of Land -disturbing Activity:...82Q W. Fourth Street (southwest intersection of W. Fourth Street & N. Green Street . . ................................................................................................................... Latitude: ....... 3q.0970................................................................... Longitude:.............. 80; 2548.............................................................. Approximate Date that Land -disturbing Activity will Commence:....... 5prin . 2022JApril : Ml)......................................... Purpose of Grading: Commercial 4Residential Multi -family ❑ Residential Single-family Lot/Lots ❑ Residential Single-family Subdivision ❑ Other Total Site Acreage: ....... 1 ;18 Acs................................ Acreage to be Disturbed; ....I..3 Acs; (including sidewalk).......... Grading/Erosion Control Permit Fee: $ ...... �. ........ Person to contact should Erosion Control related issues arise during land -disturbing activities: Narne:......... ....................................................... Email: ................. ...�r®........'.....:................................ OfficePhone: .. "... ........... Mobile Phone:.. .:..?...... .......... Fax # :................................................. Landowner of Record: (rise blank page to list additional owners if needed) ParcelPIN #:....... 025;K-2.447................................................. Tax Block #:.................................. Tax Lot #:................................... Name: ................... ........ ....................r. .................................................................................................................................................. Street Address/PO Box: .....:......"..................................... ro City/State/Zip Code: ............................... .I..... .:. :............... ................................................................................................. Office Phone.......... . _37.. . ' .............. Mobile Phone: .............. ..; .............. Fax #:.1 ..... Z....... Grading Contractor Information: (if known at tune of submitting the Erasion Control Plan for review) Value of Grading Contract: $................................................... City of WS Contractor ID#:.................................................................. Name of Grading Contractor: ............................................................................. NC License#:................................................................ ContractorContact 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*** Na►ne of Person or Firm :...... ....... ...... ..............t......................................................................................................... StreetAddress/PO Box: LIC(IfIACity/State/ZipCode 9' Office Phone: fr.. 1 ...I... 1............. Mobile Phone:. '" �,f . ............... Fax #:.... ... .. . ..... If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: ..................... .......................................................................................................................... StreetAddress/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) Naiveof Registered Agent: ................................................................................................................................................................................ StreetAddress/PO Box: ........................................................................................................................................................................... . ......... City/State/Zip Code: ...... .................................................................................................................................................... OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:................................................. The above information is true and correct to the best of any 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: ........................................ ! .�.... Title or Authority:.......... Signature: ............... tML ............. I ............................................................................................. ....... Date:... ..................................... 1. ..............t ...,........: ................... , a Notary Public of the County of...... ...0 '......... State of .... !.. M ....iNC4Y?' 1..1 ?t do hereby certify that ... �..�... ,t�,�lY ... ....(...... ...f�°� � �..1,,.. ............ , 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 .... 1 t !� ...................................... 20 ........... ..... 1111 ��.�`NOLLY M ., ;NO1://L,/T), ,i C;s Notary Public Name: ............. T y9�3 Notary Public Signature: ... .....:°....... 'C'i' �O -p z My commission expires: ............:g.. �...... ( ! C ,�!!l1i11111ti,,