NCC233279_FRO Submitted_20231103

1211(/
(10 City of Winston-Salem Field Operations Department Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
L1�IIISlofl 81G11 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: The Brookhyrst Apartments
Grading/Erosion Control Permit#:
Location of Land disturbing Activity: 121 Fayette Street, Winston-Salem, NC 27101
Latitude: 36.093986 Longitude: -80.255597
Approximate Date that Land-disturbing Activity will Commence: April 2023
Purpose of Grading:
❑ Commercial ❑x Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 4.16 ac Acreage to be Disturbed: 4.66 ac
Grading/Erosion Control Permit Fee: $ $1 ,450.00
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: William M. McClatchey, Jr Email: [e-mail]
chaucercreek.com
Office Phone: [phone] Mobile Phone: Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN# 6825-95-1 71 1 .000
Tax Block#: BL304 BU 1 Tax Lot#: L0304
Name: CCC 920 Brookstown LLC & NEW AGE COMMUNICATIONS LIMITED PARTNERSHIP
Street Address/PO Box: 3605 Glenwood Ave, Suite 445
City/State/Zip Code: Raleigh, NC 27612
Office Phone: [phone] Mobile Phone: Fax#:
Grading Contractor Information: (f 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: CCC 920 Brookstown LLC
Street Address/Po Box: 3605 Glenwood Ave, Suite 445
City/State/Zip Code: Raleigh, NC 27612
Office Phone: [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.
Street Address/PO Box.
City/State/Zip Code:
Office 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.
Type or Print Name: William M. McClatchey, Jr
Title or Authority: Manager
Signature: .... Date:��buQ(y 2 1 f 2O 3
ITefe�a L B •Ai , a Notary Public
Aof the County of/I \ekVG ,
State of � W o' Cea-rb` 111 CA�n44. , do hereby certify that `A k YY) 1�'\ • ,�L\ 4�1C...$3:, appeared
personally before me this day, and beingduly sworn, acknowledged that the above form was executed by him/her.Witness my
2 1 hand and notarial seal,this day of \--e-) Yy ,20 23
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Notary Public Name: \ �5a_ 6�t1.�.:1 �(��,11�TA,Q`„ ��
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Notary Public Signature: jtic,04691A)
Mycommission expires: " V ��� 15 1 �2 3 y A
P t (/BL\G # ary Seal
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