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Home My WebLink AboutNCC222638_FRO Submitted_20220725City of Winston-Salem Field Operations Department I Erosion Control Division UP Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 WinslonS&M 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:.Mc.Donald.'.s .#32-0302............................................................................................................................................................................. Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity: 426 Jonestown.....Road ...................................................................................................................................... Latitude:.36.073764................................................................ Longitude:..-80:338064 ..................................................................... Approximate Date that Land -disturbing Activity will Commence 8/5/2022 ............................................................................................................. Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage 0.879......................................... Acreage to be Disturbed: 0.879 .............................................................. Grading/Erosion Control Permit Fee: $.................................. Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: Tammy Kahm Email: tammy.kahm@us.mcd.com .......................................................................................................... Office Phone Mobile Phone: 919.695-6271 Fax #............................................................................................ Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #: 6804- 48-5335.................................................. Tax Block #:.3905...................... Tax LotMIA9 .......................... Name: WINSTON.DONALDS....LLC/MCDONALDS.......CORP...LC...032.0302......................................................................................................................................................................... Street Address PO Box: ,PO BOX 18257.1 ....................................................................................................................................................... City State Zip Code: COLUMBUS ..OH...43218-2571...... ............................................................................................................................................. Office Phone: ................................................... Mobile 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 Cicense#:................................................................ ContractorContact Person: .................................................................................. Contact Phone:............................................................... StreetAddress PO Box: ................................................................................................................................................................... ; ................. CityState 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: McDonald's Corporation ............................................................................................................................................... Street Address PO Box:... 0 N. Carpenter Drive, Attn: Leal DeQt. .... .... .... ..................................................................................... IL City/State/Zip Code: ..,_Chicago .. 60607 ................................................................................................................................... OfficePhone: ................................................... Mobile 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:...... The Prentice-HallCorporation System;,lnc, .... .................................................................................... Street Address PO Box: .... 2626 Glenwood...Avenue..,..Suite...550 ............................................................................................................................... City'State/Zip Code: Raleigh NC 27608 ........................................................................................................................................................... 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 .......N/A .......................................................................................................................................................................... StreetAddress PO Box: ...................................................................................................................................................................................... CityState 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. Padraic Molloy Typeor Print Name: ........................................................................................................................................................... Title or Author; Senior Counsel Signature: ..................... . I, Carolyn .A. .Bro.dersi ............................ . Illinois Stateof ........................................ 5/16/2022 ......... Date: .................................................... a Notary Public of the County of ............................................... do hereby certify that Padraic Molloy , 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 .......................... 16th......................................... day of ........ ay.................................................. , 20 ..22.... • SAL Notary Public Name C olyn A. Brodersen CAROLYNA EN ........ ............ ........... ...... INCTAiiY Pl1BL1C • BTAOPM- TE OF Notary Public Signature: I;/L..1.'... MY001074t122 7/31/2022 My commission expires: ................................................................ Notary Seal Date: WINSTONDONALDS LLC 222 Grand Avenue Englewood NJ 07631 PROPERTY OWNER'S LETTER OF AUTHORIZATION TO PROCESS PERMITS 6+/27,2022— TO: City of Winston Salem Erosion Control Division Attn: Matthew Osborne P.O. Box 2511 Winston Salem NC 27102 AP #EN2200139 To Whom It May Concern: We hereby authorize McDonald's Corporation and/or its agents to acquire permits and complete the planned work on the property located at 426 Jonestown Road, Winston Salem, North Carolina. By: Print Name: P4 Lk id f JTT r r