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Home My WebLink AboutNCC222534_FRO Submitted_20220714City of Winston-Salem Field Operations Department � Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 MINIBOOM Mailing: PO Box. 2511, Winston-Salem, NC 271C2 Financial Responsibility/Ownership Form No parson may initiate any land -disturbing activity exceeding 20,000 square feet &r Single-Fanlily Dwelling construction, 10fflO 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 Poirait has been issued. Please type or print, Please place "NIA" in the blank space if not applicable, Part A, RJR 851-1 Project quest Dock Addition ProjectName: ....... .................. ... __ .......... . ....................................................................... Grading/Erosion Contro[ Permit#:................................................................................................................................................. Location of Land-disturbingAcivitY "1..".7201.oIral Drive,'..Tobeccovite,, NC 27050D ............. ............................ Latitude: ...................................................... ........................ _. Lonartude:... ............ .. Approximate .Date that Land -disturbing Activity w[I1 Commence: Purpose of G•adin I C:oin:aercial [I Residential Muld-farnily ❑ Residential Single-family Lot/Lots Total Site Acreage: ,,............................ Grading/Erosion Control Perkllit Fee: $ ............... J Residential Single-family Subdivision C7 Other Acreageto be Disturbed: ....... .2;,,7a..................... . ......................... Pelson to contact should Erosion Control related issues arise during land -disturbing activities: Name: ,,. Win Welch .......................... o3ch@i11o�ng.m Email: .we........................I...,..co,,,.,.....,......,.......,.,....,„,,,.................,..,.,.,,...... Office Phone: .... ......... Mobile Phone: 3�6-978-b531 Fax #:,...3..3...C.a.-...b..6.<1...—...1..3...2..1.................. Landowner of Record: (use blankpage to list additional owners if needed) Parcel PIN 4:.�2911-7,1-71979. 00,0.,.....,..."I............. I ...... ,..,. Tax Block#: ,,,.. ....................... ,.... Tax Lot # :................................... Name:.......F� ..T...,1��,zip.l rds........................................................................................................................................................................... StreetAddress/1'D Box: , g ,0, B°�..29....�...........................„,,.........,,,..,,...............................,..,,....,...,...,,,...,,...,............................... ,. Winsto N 27102 Code: n..Sal.em, C City/State/Zip,,,,,,,,,,,,,,„,................... ................. ........ ................... ... -- - - Office Phone: .............................. . ., Mobile Phone:8„13-300-4350 Grading Coutractor Ittfor Ovation; (if Imown at Ume of submitting the Erosion Control Plan for review} Value of Grading Contract: $...50,000................................ City of WS Contractor ID it: 81807,,............. Naive of Grading Contractor:.. �: L: � ong,..Csoti� ��c lion„ Ga,.a,.. �p cNC License #:..,. � 7 2,2........................................ ........ Contractor Contact Person: ,.- i"..Wel.ch...................................................... Contact Phone: ... 3.36—b61�1887................ ... StreetAddross/PO Dox:. ....l3ox 4186 ......,.., City/Stata/Zip Code „,.Winston —Sad em, NC 27115...................................... ....................„,...,.,.,.,.....,,,,..,,....,.,...,....,....,..,..,.,........ 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*** R.J. Reynolds Tobacco Company Nameof Person or Firm: ......... ................ .............................................................. ............ ...... ...................... P.O. Box 2959 StreetAddress/PO Box: . ....... — .... I .......... ............................................. ............ .............................. ........ ....... City/State/Zip Code: ............ Wi.nston—S,a.1,e.m,.NC 27102................,.................................... Office Phone: .336-741-2000................... 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/P0 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) Nameof 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 forma must be signed by the financially responsible person, if an individual, or their attorney -hi -fact, or if not an individual, by an officer, director, partner, or registered agent with authority to execute instruments for the financially responsible person.) 1 agree to provide correetcd information should there be any change in the information provided herein. Typeor Print Nar= ..........Bernd Mud T............ ..................................... ........... .............................................. ............ ... Executive Vice President of Operations Title or Authority: . . . . . . . . . . . . . .....................................,.............,....... ...,.....,.,.,........,.............,...................... Signature: . ..... Date......................................................... I, ....�1l� t c7 i n r► I vS ....... .................... ................... I—........ , a Notary Public of the County of ... Foz.;S.A �......................... State of ........ .................................. . do hereby certify that --lbe"' 0.0...rn ... , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/her. Witness my handand notarial seal, this •......................... .a, .................................... day of ........,......,,..,,.,.,...............,., , 20 W Notary Public Name: Cz,. i An i n�...................... ELLA v+INk{NG Notary public - North Carolina C� n n rForsyth County Notary Public Signature: ...4�sT, J� ,.414f..Y. ' "' Im yCommission E�plrls Feb 2S, Io25 My commission expires: ...... Notary Seal