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HomeMy WebLinkAboutNCC224095_FRO Submitted_20221213City of Winston-Salem Field Operations Department I Erosion Control Division Office: 100 E. First Street, Suite 328, Winston-Salem, NC 27101 %HS1111MMI 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 Gradino.rosion Control Permit has been issued. Please type or print. Please place "N/A" in the blank space if not applicable. Part A Pmjcct Namc:. Carolina ..Storage......Expansion.................................... Grading/Erosion Control Permit #: .............8070...5...7............................................................................................................................................... Location of Land -disturbing Activity: , 3801.Wabash....Bl..vd., .Winston-Salem.......,....North...Carolina.......................................... ........................................................................... Latitude: 36° 9'39.23. N .... Longitude:.80'.19'42.1.8��W......................................................... ..................................................................................... Approximate Date that Land -disturbing Activity will Commence: ... 1 /01 /2022 .......... ................... ........................................................... Purpose of Grading: ® Commercial ❑ Residential Multi -family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other Total Site Acreage: 1 93 acres 1.20 acres gJ.:��.g!ges ............................. Acreage to be Disturbed:................................................. Grading/Erosion Control Pennit Fee: $ �4 Person to contact should Erosion Control related issues arise during land -disturbing activities: Name: ..Cameron Hoover................................I........ Email:..Camhoover1.1..a� mail:com.................................................... Office Phone: ,717 :682.5595 Mobile Phone: Fax #........................................................................................................ Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN t1:... 6808:70.911.1................................................. Tax Block tl:..820....................... Tax Lot th-34.8.8 ...................... Name: ................................................................................................................................................................................... Street Address/PO Box:.. 3801 Wabash ..Blvd.. . ................................................................................................................ City/State/Zip Code:......... Winston.-.Salem,..NC.... 27106.......................................................... .............................................................. ....................................... Office Phone: 717 :682.2688.................... Mobile Phone: ....................... Fax # ......... .2......... ............................... ............. Grading Contractor Information: (rf known at time of submitting the Erosion Control Plan for review) Value of Grading Contract: $ . TBD....................................... City of WS Contractor ID #:,TBD...................................................... Nameof Grading Contractor: ............................................................................. NC License#:................................................................ Contractor Contact Person: ....................... Street Address/PO Box:........... City/State/Zip Code: ................................... .............................................. Contact Phone:............................................................... ............................................................................................................................................ Part B Person(s) or firms who are financially responsible for this land -disturbing activity: (use blank page to list additional person(s) or !inns if needed) ***Contractors are not considered financially responsible for property not under their ownership*** a Name of Person or Firm: .... Old Town Stor..............................e, LLC ................................................................................................................. StreetAddress/PO Box: ...... 3801 Wabash Blvd............................................................................................................. City/State/zip Code...........Winston-Salem, ....NC.27106........................................................................................................................................... Office Phone:.71,7.682.2688 .. 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: ... Llttlewo0d,Law,,PLLC,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,•„........................ ............................................. Street Address/PO Box: ......... 4208 Six Forks Rd., Ste;1000....................................................................................... City/State/zip Code:........... Ralei9N.NC27609............................................................................................................ OfficePhone 919.518.9508 ... 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: ....Cameron......Hoove..r.......................................... ............................................................................................ .............................. Street Address/PO Box: 3028 Spooky NOOk Road........................................................................................ .............................................................................................. City/State/Zip Code: ............. Manheim�.PA...17545....................................................................................................... Office Phone: 717.682.2688 ... 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 infonnation provided herein. Typeor Print Name: .... Cameron ..Hoover. . .................................................................................................................................... Titleor Authority........O......w..n.er.......................................................................................................................................... Signature .............................. Date: ..If 2�122 ........................................................................................ ............................................... I. ............ .! .. `.r ........................................................ , a Notary Public of the County of..Z/.:4"l ................................ . State of ..... �......... do hereby certify that 5 �l ""���� %�. ........................ Y Y........................................................................ , appeared personally before me this day, and being duly sworn, acknowledged that the above form was executed by him/hcr. Witness my hand and notarial seal, this..............................23................................... day of ................................................ , 20 2Z Notary Public Name: ........... .......... �.�� ..... NotaryPublic Signature: ..................................................... My commission expires: 1 U�� �2a2S ........................................................... Commonwealth of Pennsylvania - Notary Seal Chad M. Boyer, Notary Public Lancaster County My commission expires Cetoter 17, 2025 Commission number 1015555 Notary Seal