NCC231227_FRO Submitted_20230523

W./ City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
I llnslIMSalem 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: Immunotek BioCenters
Grading/Erosion Control Permit#: EN#2200269
Location of Land-disturbing Activity: 5516 Winona St NW
Latitude: 3.6,1.61.124 Longitude: 80.322454
Approximate Date that Land-disturbing Activity will Commence: 03/01/2023
Purpose of Grading:
x❑ Commercial ❑ Residential Multi-family El Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 1.737 Acreage to be Disturbed: 1.89
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Larry Martin Email: Imartinimmunotek.com
Office Phone: Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 6aQ 9.0 7..O28..&G&Q8:SQ.t007 Tax Block#: Tax Lot#:
Name: 3735 Reynolda Road LLC
Street Address/PO Box: _ 4 Star Point,Ste 204
City/State/Zip Code: Stamford,CT 06902
Office Phone: [phone] Mobile Phone: Fax#:
Grading Contractor Information: (if known at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: $ City of WS Contractor ID#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/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: ImmunoTek Bio Centers, LLC
Street Address/PO Box: 1430 E Southlake Blvd Suite 200
City/State/Zip Code: Southlake,.Texas 76092
Office Phone: Mobile Phone: [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. gis.t x.4IAgcnJ.Inc
Street Address/PO Box- 4030 Wake Forest Road, Ste 349
City/State/Zip Code: Raleigh,.North.Canul.ina.2.76.09
Office Phone: [phone] 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)
Name of Registered Agent:
Street Address/PO Box:
City/State/Zip Code:
Office Phone: 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 should there be any change in the information provided herein.
..-----.
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Type or Print Name: J 11-4-/✓'-
Title or Authority;. 0
Signtre' .Th..! Date: ..l 140/Z3
I,..01.49..( c'in , 'vt 'Ka , a Notary Public of the County of TO ( v' 14 ,
State of Te 'S , do hereby certify that 36A' j I Ile'r S , appeared
personally before me this day,and being duly sworn,
orn,acknowledged that the above form was executed by him/her.Witness
my
hand and notarial seal,this 1.4, day of �uLfti ,20 `S
+ ..y� ����1YP��i„ MORGAN WHITNEY HOWP,RD
Notary Public Name: I110 !' Jit� �20`, `e :Notary PublicI State O Texas
f tife Comm.Expires 05-13-2024
Notary Public Signature. `�� "(W-1*;� Notary ID 130639460
My commission expires: .5 I ~ 202`/ Notary Seal