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Home My WebLink AboutNCC215446_FRO Submitted_20210930�M/frRl�► IAf City of Winston-Salem/Forsyth County Inspections Division a 100 E. First Street, Suite 328, Winston-Salem, NC 27101 INSPECT' OHS DIVISION Financial Responsibility/Ownership Form Erosion Control Ordinance No person may initiate any land -disturbing activity exceeding 20,000 square feet for a single-family dwelling or 10,000 square feet for any other purpose, before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Erosion Control Section of the City of Winston-Salem/Forsyth County Inspections Division. Please type or print. If a question is not applicable, please place "NIA" in the blank space. PART A Project Name: Hlllcrest Storage Permit # ............... •.•........•............................................•............................................................ Location of Land -Disturbing Activity: Winterhaven Lane in Hillcrest Center off S. Stratford Road ..............•....•..................................•....................................I........................... Latitude 36.0501 N Longitude 80.3263 E Approximate Date to Commence Land -Disturbing Activity:••................................................................................................ ---------------- Purpose of Grading: $ Commercial 9 Residential Multi -family 9 Other (No development proposed) 9 Residential Single Family lot 9 Residential Single Family Subdivision Total Site Acreage: 1.54 Acreage to he Disturbed: 1.54 permit„e•�:,,,,,,,,,44.....................................................•••............-......... ................•........ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name ..........Robe,rt,High..................... ••..•........................... E-mail address...robert@raberthighdevelopment:corn Telephone ....(91•0119.0- .4.90........•••.•....... Cell #........... Fax #...................... Landowner of Record (use blank page to list additional owners): .......Coastal Mini„Storage. of.Ca.pe„Fear,..LLC,•............ .............................. Name Owners phone # 324 Greenville Ave Street Address/P.O. Box ............ Name .....•... •............................................................................ Street Address/P.O. Box Wilmington, NC 28403 City/State/Zip Code City/State/Zip Code (910) 790-9490 ........... ••..•...•.................... Owners phone # Tax Block #: 6803 Tax Lot #: 97.28............... Zonis MU-S ...... g...............................•.•..... Zoning Approval: ....................................... Contractor Information Required Prior to PerinitIssuance North Carolina State Law requires that contractors be licensed to perform work valued at $30,000 and higher. All contractors must have a City of Winston-Salem contractor's ID#, available at no cost through the City's Revenue Office. Value of Grading Contract Name of Primary Applicant (Grading Contractor) Street Address/P.O. Box City of W-S Contractor's ID # Contractor's N. C. License Number Contact Person for Contractor City/State/Zip Code Contact Person's Daytime Phone Number PART B 1. Person(s) or fin-n(s) who are financially responsible for this land -disturbing activity (use blank page to list additional persons or firms). Contractors are not considered financially responsible for property not under their ownership. Coastal Mini Storage of Cape Fear, LLC ..................................................................................................................................................................................................................................................... Name of Person or Firm Name of Person or Firm 324 Greenville Ave ....................................................................................................................................... Street Address/P.O. Box Street Address/P.O. Box Wilmington, NC 28403 City/State/Zip Code CitylStatelZip Code (910) 790-9490 ............................................................................ Daytime Telephone # ............... ................... .,......................................... Daytime Telephone # 2. If the financially responsible party is an out-of-state resident, give the name and street address of the registered in -state agent. ......................................................................................................................... Name of the Registered Agent ................................ ..,...........,........................................................I............................ City/State/Zip Code Street Address/P.O. Box ..................................................................................................................................... Daytime Telephone # 3; If the finapcially responsible.party is a partnership, give the name and.address of each General Partner (use blank page to list additional partners). .................................................................................................................................................................... .................... ..........I........................................................................... Name of the General Partner Name of the General Partner ........................................................................................................................... Street Address/P.O. Box Street Address/P.O. Box -.............................................................................................................................................................................................................................................................. City/State/Zip Code City/State/Zip Code ......................................................................................................................".,............I................... Daytime Telephone # Daytime Telephone # 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 his 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. ......Robert M...H.jq........................................ ....Manager......................... Type or Print Name Title or A thori .................................................................... .......... Q ......................................................................... Signature Date I, ........ a Notary Public of the County of .....P"elve ........................................................................................ St to of North Carolina, do hereby certify that appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this . ........, day of , 20� . ........... . My commission expires: �'. ............