NCC242281_FRO Submitted_20240731

(I/J/ City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
WmslonSalem 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: Stadler America
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 3089 Centre Park Court, Winston Salem, NC 27107
Latitude: 36.052526 Longitude: -80.172839
Approximate Date that Land-disturbing Activity will Commence: 7/1 Q/2QZ4
Purpose of Grading:
® Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 4.58 Acreage to be Disturbed: 1.85
Grading/Erosion Control Permit Fee: $ 844.00
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Henry M. Kennedy Email: [e-mail]
Office Phone: [phone] Mobile Phone: Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 6853-39-3993 Tax Block#: 2638 Tax Lot#: 118D
Name: Stadler Property LLC
Street Address/PO Box: 1301 Avenue of the Americas, 21st Floor
City/State/Zip Code: New York, NY 10118
Office Phone: [phone] Mobile Phone: [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) ***Contactors are not considered financially responsible for property not under their ownership***
Name of Person or Finn
Stadler America, LLC
Street Address/Po Box: 9050-C West Market Street
City/State/Zip Code: Colfax, NC 27235
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 InCorp Services, Inc.
Street Address/PO Box. 176 Mine Lake Court, Suite 100
City/State/Zip Code: Raleigh, NC 27615
Office Phone: [phone] Mobile Phone: [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: Henry M. Kennedy
Title or Authority: Chief Operating Officer
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