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Home My WebLink AboutNCC221428_FRO Submitted_20220412WV City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WHO111-841em 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: ..Take 5.Car.Wash ....................................................................................................................................................................... Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity: 6024 & 6034 UDiversity Parkwayz.Winston Salem,..NC......................................................... .... .... ........ Latitude: .36:1.90270.................................................................. Longitude:..80.277820.................................................................... Approximate Date that Land -disturbing Activity will Commence: .Ap.....1, 2022,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage:.:25............................................ Acreage to be Disturbed: 44......................................................... Grading/Erosion Control Permit Fee: $ ...1. 46..($ 42 +$202+$202) Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: Steve De Lisle . Email: steve@Jetabuilders.com ..................... ......................................................................................... Office Phone: (404) 400-7290 Mobile Phone: �407) 280-9905 Fax #: Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN .................................................. Tax Block #:. Block.E.................... Tax Lot #:. Q.U......................... Name: .Boin US Holdco, lnc:..�dba "Take 5 Car Wash.................................................................................................................. Street Address/PO Box: Cite 700 ......................................................................................................................................... City/State/Zip Code:.Greensboro NC 28202........................................................................................................................................... Office Phone: 704 :377„ 8855...................... Mobile Phone: .28.1..-6.60.-9.58.3 ......................... Fax #:................................................. Grading Contractor Information: (f known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $.5.9,.QQHQ .............................. City of WS Contractor ID #: Name of Grading Contractor: ... APC. Pipeline..Serv.ices...LLC....................... NC License #: ............... Contractor Contact Person: Blake Crim Contact Phone: ...333-595-4765 .................................................................. 4809 Brinkley Rd StreetAddress/PO Box: ..................................................................................................................................................................................... City/State/Zip Code: ,,,Belews Creek NC 27009 ................................................................................................................................................................. WV City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WHSINS' lem 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 ProjectName: ....................................................................................................................................................................................................... Grading/Erosion Control Permit#:.................................................................................................................................................................. Locationof Land -disturbing Activity: ............................................................................................................................................................. Latitude:......................................................................................... Longitude:............................................................................................ Approximate Date that Land -disturbing Activity will Commence: ............................................................................................................ Purpose of Grading: ❑ Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage:...................................................... Acreage to be Disturbed:....................................................... Grading/Erosion Control Permit Fee: $.................................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: .................................................................................. Email:.................................................................................................................. OfficePhone: ................................................... Mobile Phone:...................................................... Fax #:................................................. Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #:... $ .-. Q-$ `J.................................................. Tax Block #:.Block....................... Tax Lot#:..Lot.2......................... Name: ONSC WS, LLC / Sam Simpson.................................................................................................................................................. Street Address/PO Box: 14Q1 Sunset Drive, B ............................................................................................................................................................ City/State/Zip Code:..Greensboro NC 27408.......................................................................................................................................... Office Phone: .(336) 707-5717 .............................. 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:............................................................... StreetAddress/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: Boing US Fioldcot lnc; (dba "Take 5 Car Wash"),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Street Address/PO Box: 4 9 S Church .St...,..Suite.....700 ........................................................................................................................ City.'State.Zip Code Charlotte, NC 28202 ........................................................................................................................................................... Office Phone:. O4 ;377 8855..................... Mobile Phone:...................................................... Fax #:................................................. If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: .................................................................................................................................................. StreetAddress/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) Name of Registered Agent: Street Address/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 instruments for the financially responsible person.) I agree to provide corrected information should there be any change in the information provided herein. Boing US Holdco, Inc. Type or Print Name: By. Scott, O:Melia .......................................................................................................................................... Executive Vice President Titleor Authority: ......... .. .................................. .......................................................................................................... Signature: Date:. April 5 2022 gn I, .. k-A...... 4 i '........................... . a Notary Public of the County of.. ................... j. State of ......... �� `� ..1 .................. . do hereby certify that ...........5.c.0.14......0.. ...................... , appeared personally before me this day, and being quly sworn, acknowledged that the above form was executed by him/her. Witness my ` hand and notarial seal, this ................6- .......-1`�......................................... day of.......%.t............................................. , 20 laal. I``````p`p�u�uululurrpq p�+''i Notary Public Name: .....:{ .ia..l,... ��?.?t l� ,�•�•�,'�� 9� Notary Public Signature: lA.�� j " 1 �%.,�?,�-�%�/J+ CO 0 p r �i0' 0a My commission expires: .................. 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:ONSC WS, LLC / Sam Simpson Street Address/PO Box: .1 1 S.y.n.set Drive, B City/state/zip Code:Greensboro,..NC 27408.................................................................................................................... Office Phone: .W1.Q), 707 ;5717................... Mobile Phone: ........................... Fax #: ........................... ............... If the financially responsible party is an out-of-state firm, provide information for the in -state registered agent: Nameof Registered Agent: .................................................................................................................................................. StreetAddress/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) Name of Registered Agent: StreetAddress/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: .;54 .S1mPSOn.............. Title or Authority: .Man....q . . Signature:......................................................................................................... Date:... ...... ...................... 1� } 1 .. :... ' 1 �.T�.1t................................. . a Notary Public of the County of .. t.�-ul..�� rCL................. State of?�:.4.. 1 1 �!rf `... , do hereby certify that 6SZSt<Y.1...� `�................................. . appeared personally before me this day, and --being duly sworn, acknowledged that the above form was executed by him/her. Witness my hand and notarial seal, this ........1� �.................................................. day of.0+h.� ............................................ , 20 %N0III I I I1111111p1k� Notary Public N. ..........L:..� �� ref ... `.�`�� c�,A10nfF;C j►��i �'•' PY �• NotaryPublic Si atur •' gn .lr�.f}...�..� .. .... ' �; _ . � � C7 Z Mycommission expires: ...................... d Notp' 4: up ''��1111lf1I Ilt11ti��,N