NCC231633_FRO Submitted_20230530

',I City of Winston-Salem Field Operations Department I Erosion Control Division
t V Office: 100 E.First Street, Suite 328,Winston-Salem,NC 27101
WlnslnnSalem 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: Harbor Freight at Glenn Crossing
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 1410 Glenn Center Drive
Latitude: 5b..Q7..9.90 Longitude: -AA.,112474
Approximate Date that Land-disturbing Activity will Commence: July 2023
Purpose of Grading:
El Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 1.4 Acreage to be Disturbed: 1.4
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Xx Email: ^^
Office Phone: nip. Mobile Phone: [phone] Fax#: n/a
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#• 6867-16-1898 Tax Block#: Tax Lot#:
Name: West Point Village Associates
Street Address/PO Box: 424 W Mountain St
City/State/Zip Code: Kernersville NC 27284
Office Phone: n/a Mobile Phone: 33s?-$17-46Q2 Fax#:
n/a
Grading Contractor Information: (f 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 License#:
Contractor Contact Person: Contact Phone:
Street Address/PO Box:
City/State/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: HENBELL PROPERTIES, LW
Street Address/PO Box: 3510 Wheeler Road
City/State/Zip Code: Augusta, GA 30909
Office Phone: Mobile Phone: [phone] Fax#: n/a
If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered Agent Corporation Service Company- Hatch, Little & Bunn, LLC
Street Address/PO Box 2626 Glenwood Ave, Ste 550
City/State/Zip Code: Raleigh, NC 27608
Office Phone: [phone] Mobile Phone: n/a Fax#: n/a
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: ilia
Street Address/PO Box: n/a
City/State/Zip Code: n/a
Office Phone: n/a Mobile Phone: n/a Fax#: n/a
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.
Type or Print Name: Alan Dennis Trotter
Title or Authority Authorized Signatory
Signature. ....... .if19-- Date: ..o.l.i. .R./.z0
I, ....I�.0.-tarry Eq.!?.Lr.t , a Notary Public of the County of..02.►.A4tm>?r a
State of..d.c.org to. do hereby certify that A la ii Q.4.IY.11. Ttvi-Vx 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 00" day of a.n wa.(:9 ,20 Z.;....
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Notary Public Name: ..h l l�.�l.l� 'aft ��;,:„OTAR j.�rj.
Notary Public Signature: TFiattleiele 4 = EXPIRES
GEORGIA
My commission expires: j u.3 /. 0 e..S 10-03-2025 .
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