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HomeMy WebLinkAboutNCC221698_FRO Submitted_20220503City of Winston-Salem Field Operations Department I Erosion Control Division CiMce_ - F 100E, irst Street, Suite 328,Winston-Salern,NC27101 Wrwn&ilcin Mailing: PO Box 2511, Winston-Salem NC 27102 Financial Responsibility/Ownership Form No Person may initiate any land-dislorbing x6vicy exoxeding 20,000,qnare J'ect for Single -Family Dwelling construction, 10,000 square feet for any other oon-exempt purpose, or part of ek larger common plan ordevelopment exceeding these thresholds, before this form and tin weeptable Erosion Control Plan have bean subimilled, reviewed, and appi­Qvrd by the City of Winsion-Salem Erosion Coniml Division and Grad ing;Erosion COW01 Ptnult has been isstwJ. Please type or print. Please place "N A" in the blank space if not applicable_ PartA . . ..................... .... ­­.._.­_.­ ..... . ......... ............. .... . ........ . .... ­ .. .... GYM ing 1-M)sion Control Permit 9: __ IEN2 I OD281 ................... .... . ....... I . . ... . ........................... _ ... ............................ ........ I— ......... Location of Land-di.siurbing A-clivily: .;jq5.Mtdical Center Blvd .. . Medical ................. ... ­­­ . . .... . ................. ­­­­­ . . ... . ................... . ... . .. . .. . .... . ......... Latitude: ............. _ ....... . . ... . ... . .......... .. . ... . ............. A ppix)xj ma le Dale that Land- disturbing Activity wilt CominenQe, . .................. . ... . ... . ... . ............... Purpose of Grading: [N Carninemial U R"idepifial Muld-fainfly El ReAdealial Single-lidmily Subdivision El Residential Single-family Lot/Lots 0 Oliver Total Site Acreav: 319 -1-1 ....... .......... ... . ... Gradingi Erosion Control Permit Fe(,-: S ............... Acreage 10 be Disturbed; .1, -.11--­­ . .................................... Person to contact should Erosion Control related issues arise during land -disturbing activities: Narne: ...... . .............................. rin.jil. jsy�a 01n .!�2p��fiblUMX .............. .......... ­­'­ . . ................ Office Phone. ..................... ....................... Mobile Phone: .336.399-2288 .... . .. I—— ... . ................ .... ­­_ Fax .... . .............. Landowner of Record: (u.ve blank page Yo Aw Mdifioned owners q-neeeled) Parcel PIN N:fi825-43-8944 - ... . .................. . ­­­­ . ... . ................. Tax Block 4. �2153 429 . . ... . ..... Tdx Lot .. . .... . ....... Wake Forest Uniy Name . . ......................... verstjtakth§siences ..... .... . ..................... ­­ . . .................................... _ ... . ........ ................ $li'vei Address. -TO Box -10 1 R Medical Center Blvd. ....................... ­­­­ ... . .................. . . ..................... ................ . .. . ................... . Ci ly,,State,'Zip Code..wimsion-sa 11 NC 27157 ­­1­1 . ..... .......... ­1­1..................... ... . .................... . ...... . . ............................. . ... . ... . ............. Office Phone: " 3 1 3 1 6. 716,7t83 . 1 - -­ ....... Mobile Phone: ........... .... . ... ­_ Fax 0 .... . .. . . . ... . ......... . .. . ......... Grading Contractor I n rfj rrn a t ion - off known al lime qfsubiniifiprg the En)Lvion Coijil-ol Plan 16r j -evie it) Value o f G Fad ing Ctmlracl, S .. . ... .......... ­­ .. . .... . ... . .......... City of WS Contractor JD #: . . .. . .................................. . ................... Name ol'Grading Contraklor . ......... .......... . .... . .. . ... . ............... NC License #: ........................ ... _ ... . .. . .... . .............. Contractor Contact Persan . . . ... . ... . .... . .. . .................... . .... . ..................... ___ Cum act Phone: ....................... . ... . ... . ........ . .... Stroct AddressiP0 Box....._.._ ... .. . ......................... . .. . .... . ... . .... . ........... Cily!Slate,7-ip Code . . . ............................. Part B Person(s) or firms who am A0skncially responsible for this land -disturbing activity: We blank pftgi� to list addiIionaI parson�sl or Firnis if needed) 's*Contractors are not considered fiimucially responsihie for proparty rxlt under their ownership**s 1 atne of Person or Firm: pke Foresi llniversitY l lealth Sciences Slwel Add rms', O Box: 3�1 B Medical Center Blvd ityiurler'7ipCode, ........... ton=Salem, NC 27157 36-716-7883 336.345.8%0 ...... ....... 3.... OtrceMono: ................»............................. Mobile Phone: .... ..... ..........»..,,...,,.................. .... Fax N:,».................. .......... ..... ............ If the ftnan-CinIly responsible part)' is 31a out-of-state lirm, provide informslion for the tn-stsrle registered agent: Name ol` Registered Agi 1nl.,„................................,........._.-_..................... _....... ..--.-. .......................... ..... SlreelAddtet.,,,`P(l Box:.............................................,......--,.........,..........,....., ..............,. „ Otyf late+ Il] Code: ...... - ........................... Offce Phohsc ,................... .»........................ Mobile Phone; ........ -...,,................................ [fax :.............. ...4... »........ »..,,.....,..... If the financially responsible party is a partnership, provide information for each General Partner: (Ir-.e blank, peke to list a(Mitiostial parirrers il`netded) Nameof Register-Od Agerti: ................ .............. .......... ............ ..... ....,,....,,,....,............ ».......,,....,,.....,......... , .» ,».....,,,....,... ......». Street Address. -TO Box: ............. --- ....... »..................... .... ... ,.... .................. ......... .».,,»..,,....,,.....,,...........- ...».,,.....,....,............. ,... C'ityf5tate,' ip Code: Office Ph(mle; ,,............... ....... ............ ...... ....... Mobilo Phone; ,, ............ , .............................. Fax #:.... ........... ....V , ....................... 'Fife above hlionmaiion is trtre and correo to ille best of 11)y knowledge and beliel`and was provided by mie under oallt. (This Bern must be signer! by the financlaliy msponslhie person, if an IIIdIVidual- or their allorney-ill-fact, of If not an individual, by an officer, director. partner. or regislered ageni with authority io execute unslntments for the financially mspwnsible per n,} I Agree to provide cormcled information should there he any change in the info ntialion provided herein, Typeyr Print Name: — - ................................................................................... Title or AutWrily....... /i % - Signalure: . ....................... ,............................... ....,-...... .»... ........ ............... -..... .... ..... . Dale 1 I, ........ ! .,..�f' !1............................ », a Nolary Public of the Counly of... `.ill t�. Staw of .,, .............. ..................»...... . do hereby crrlify Thar ,,.. � 4 .-. f, ! ..,..........- .................. , appeared persona Ily bE fore rrle I h i s day, and toeing dtily sworn. acknowledged that the above form was executed by hi When Witness my ilalyd and notarial seal, this ,,,...,.................................... . ,,,, .., day of ... IFA&V-e�X............. ...... ...... .»..,...,,, , 2022- . J Watery lout& Notary Public Name; ....&Jlle .P- For" County North Cemllna Tlooly Public signal Ire: � ,..... ;? .... , MY ComrNsskin Explrm Bl31.-M26 Mycon-Imission expires: .. f. lx ,,........�..,,...-,»..,,,..... otO)y .Seal