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Home My WebLink AboutNCC223246_FRO Submitted_20220915City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 W[I6SI011,&{l 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: West Edq'e - MultiFaml1y............................................I- .................................................................................................. Grading/Erosion Control Permit#:.................................................................................................................................................................. Location of Land -disturbing Activity: 2107 Robin Lark Circle .................................................................................................................................................... Latitude: .N360.07' 11: $0'�............................................ Longitude. W80° 22' 17.42" ......................................................................... Approximate Date that Land -disturbing Activity will Commence: `I UIy 2022 .................................................................................. Purpose of Grading: ❑ Commercial ❑x Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage 38........... Acreage to be Disturbed 2 .................8.39........0 ....................8.70 ac ................................................ Grading/Erosion Control Permit Fee: $ .6,298.00 Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: ScottUnderwood Email: sunderwood@woodfieldinvestments.com /....................................-.................... .................................. Office Phone:.1919� 740-8877 Mobile Phone: Fax # .................................................................................................................................................... Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN #: 5896-55-2142 .......... Tax Block #: 461.8 Tax Lot #:.1.rJ1 ............................................ Name: West Edge Adams LLC ........................................................................................................................................................ Street Address/PO Box:.PO Box .....2085...........0 ................................................................................................................................................ City/State/zip Code:.Charleston...,...SC....29413............................................................................................................................................................ Office Phone:.(843)..941-4027 Mobile Phone: .(919)..606:4378........... 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: .L OWde..r.....', I.nc............................................. NC License .............................................#'................................................................. Contractor Contact Person: Tyler Beam Contact Phone: 300-6865 ........................................................................................................................................ Street Address/PO Box: 281.n.Griffith Road ...................................................................................................................................................... City/State/zip Cade: Winston-Saleml NC 27103 ................................................................................................................................ 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: WF/CP West Edge Apartments, LLC ................................ Street Address/PO Box: 82.10 Creedmore Rd ., Suite 2 ..........10............................................................................. City/State/Zip Code:.Raleigh, NC 27613-1388 //...................................................................................................... Office Phone: Pj.?) 740-8877 ..... 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 attomey-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: M. Scott Underwood ...................................................................................................................................I.................... Titleor Authority: .President............................................................................................................................................................ Signature:...........................................I.......I....... Date:.,... ?1491�. I, .....J.�� r11I`�,� h/�..�..�r�}L:.� � ....................................A. aI Notary Public roffthe County o�f�......n�/lalhLl .. ...................... State of ..NU.Y.i �.l..�kVx.51.}.�.!.�!A. , do hereby certify that ...1`1��.1.�.N�.�! �.�..11.Y.11J�h.wtlt/.�,`, appeared personally before me this day, and bein5duly sworn, acknowledged that the abov form was executed .by' him/her. Witness my hand and notarial seal, this .............. .......... L. -.............................. day of ... t%:C.dlll�r.IirS,c!......................... , 20 QU?A., i v00 LY Nt q ��'b�. Notary Public Name: � v. n....� .4. S. ��``' 4 • r� 0 T,q Notary Public Signature: ... = y ' r- co My commission expires: ....114.... ........ ►� •• 7 Se47