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HomeMy WebLinkAboutNCC232433_FRO Submitted_20230814 11l!J City of Winston-Salem Field Operations Department j Erosion Control Division Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27 I 0 I t hlslonSalei 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: Quality Education Seed in Soil Addition Grading/Erosion Control Permit#: Location of Land-disturbing Activity: 5151 Lansing Drive 36 .1506987 -80 . 2056921 Latitude: Longitude: Approximate Date that Land-disturbing Activity will Commence: Purpose of Grading: © Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision ❑ Residential Single-family Lot/Lots ❑ Other 8 . 13 1.428 Total Site Acreage: Acreage to be Disturbed: 728.46 Grading/Erosion Control Permit Fee: $ Person to contact should Erosion Control related issues arise during land-disturbing activities: Name: Jimmie Carson Email: jimmie@smithsonnet .com Office Phone: 2 5 2-9 7 7-3 0 5 5 Mobile Phone: Fax#: 2 5 2-9 8 5-2 8 6 4 Landowner of Record: (use blank page to list additional owners if needed) Parcel PIN# 6847-45-1746 / 6847-35-8902 Tax Block#: Tax Lot#: Name: Seed in the Soil, Inc. / Dr. Tamara Turner Street Address/PO Box: 5012 Lansing Drive City/State/Zip Code: Winston-Salem, NC 27105 Office Phone: 3 3 6-74 4-713 8 Mobile Phone: Fax#: Ext . 3005 Grading Contractor Information: (fknown 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 Finn: Seed in the Soil, Inc . / Dr. Tamara Turner Street Address/PO Box: 5 012 Lansing Drive City/State/Zip Code: Winston-Salem, NC 27105 Office Phone: 3 3 6-74 4-713 8 Mobile Phone: Fax#: Ext. 3005 If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent: Name of Registered Agent. Street Address/PO Box. City/State/Zip Code: Office Phone: 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: James E, Gadson 1709 CARRAIGE COVE LANE Street Address/PO Box: City/State/Zip Code: Winston-Salem, NC 27127 336-414-6583 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 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. Tamara M. Turner Type or Print Name: CEO Quality Education Academy Title or Authority: ... July 18, 2023 Signature: Date: Tonya M. Oliphant Forsyth I, , a Notary Public of the County of North Carolina Tamara M. Turner State of ,do hereby certify that , 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 1 day of '``�j ,20 otto111111111/p of Tonya M. Oliphant � . Net, Notary Public Name: � '(ARY d�of' -A _ MY p�p,ES s Notary Public Signature: ... _.... -•• r. cOMM��,oN 2 E.) 12/16/24 My commission expires: h IlY7'H nC'OJ��'r