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Home My WebLink AboutNCC230011_FRO Submitted_20230111' 1 City of Winston-Salem Field Operations Department I Erosion Control Division Office: ]00 E. First Street, Suite 328, Winston-Salem. NC 27101 WHIfin-Salem Mailina: 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 thresliolds, 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 bas been issued. Please type or print. Please place "N/A" in the blank space if not applicable. Part A Project Name:.,HANES MILL STORAGE ................................................................................................................................................................ Grading/Erosion Control Permit #: Location of Land-disturbingActivity: , HANES MILL , WINSTON-SALEM, ..RD..............................................................NC.............................................................. Latitttde:.,36:188215 Longitude:..-80.270286 ....................................................................................................... ., 03/01 /2023 Approximate Date that Land -disturbing Activity will Commence:............................................................................................................ Purpose of Grading: ZI Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 5.343 Acreage to be Disturbed: 3.875 ............................................................................ ........... ..... Grading/Erosion Control Permit fee: S .1,248,00 @4.2.00 + 606.00) Person to contact should Erosion Control related issues arise during land -disturbing activities: Namc:.... Jim Sandknop ... Email:.,Jim.sandknop@leoterradevelopment.com .............................................................................................. Office Phone: ............(� 362 - 1716 Mobile Phone: ........... Fax #: Landowner of Record: (use blank page to list additional owners if needed) 6828-59 1546 BL6508 L0005 ParcelPIN#:....................-............................................................ Tax Block #:.......... ....... ................. Tax Lot {:................................. LeoTerra Hanes Mill Storage, LLC Name:.................................................................................................................................................................................................................... Street Address/PO Box: ... 110 - a Shields........Park....Dr ............................................................................................................................................ city/state/zip Code:....,Kernersville, NC 27284 Forsyth ..................................................................................................................................................................... Office Phone:....�� 354-8095............. Mobile Phone:...................................................... Fax 11: .................. Grading Contractor Information: (if known (i[ time of'suhmilling the Erosion Control Plcrn for revien") Value of Grading Contract: $................................................... City of WS Contractor ID#:...,.............,................................................ Name of Grading Contractor: .............. .............................................................. NC License#:................................................................ ContractorContact Person: .................................................................................. Contact Phone:............................................................... StrcctAddress/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:..LeoTerra Hanes ill MStora9.e, LLC Street Address/PO Box:....110 . a Shields Park Dr ............................................................................................................................ city/state/zip Code:...Kernersville, NC 27284 Forst' h............................................................................................. Office Phone:...�336� 354-8095.............. Mobile Phone 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 instrurnents for the financially responsible person.) I agree to provide corrected information should there be any change in the information provided herein. r�� Type or Print Narne:.....�rt,S�>�.................. L`.fQ.r4.5�....................................................................................... Titleor Authority: ..... Ma.......:C.-�........................................................................................................................... Signature: .............. ....... .�lJ.`....... ....................................................................................... Date: .... 1.�.�3.�........................... 1. ................. A.^`...s .................. , a Notary Public of the County of ........�i� v. �.�................, State of ..�+N 1....��`.�.!..`�'�1, do hereby certify that..........t........... , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my � rd hand and notarial seal, this......................................................................... day of ...................................... , 20 .��.. '`)V , Notary Public Name: ..°a•�.?.!�. �c.Yb...... �''G°tc+miss�of,0 Notary Public Signature: _ G� AorARY CD My commission expires: .....ff...... 9 ......................... ' ' sr =, O 26 Coui �"