NCC232648_FRO Submitted_20230901

Lati
City of Winston-Salem Field Operations Department I Erosion Control Division
LW Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27101
11051811Sfl1011 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
Chick-fil-A Peace Haven
Project Name:
Grading/Erosion Control Permit#: ...
s
Location of Land-disturbing Activity: 1925 N. Peace Haven Road% Winston-Salem NC
Latitude: 36.11795 Longitude: -80.31286
Approximate Date that Land-disturbing Activity will Commence:
Purpose of Grading:
El Commercial 0 Residential Multi-family 0 Residential Single-family Subdivision
0 Residential Single-family Lot/Lots 0 Other fil0
Total Site Acreage: 1.05 Acreage to be Disturbed: I'I o
Grading/Erosion Control Permit Fee: $ .........h i y
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Chad Ross-Chick-fil-A; Inc. Email: chad.rossecfacorp.com
Office Phone: Mobile Phone: [phone] Fax#:
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN#'6816-24-2313 Tax Block#: Tax Lot#:
Name: Chick-fil-A INC
Street Address/PO Box: 5200 Buffington Road,
City/State/Zip Code.Atlanta GA 30349
Office Phone: [phone] Mobile Phone: N/A Fax#: N/A
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: TBD 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: Chick-f11-A Inc
Street Address/PO Box: 5200 Buffington road
City/State/Zip Code: Atlanta GA 30349
Office Phone: Mobile Phone: [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. CT Corporation
Street Address/PO Box- 160 Mine Lake Court, Suite 200
City/State/Zip Code: Raleigh, NC 27615
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:
Street Address/PO Box:
City/State/Zip Code:
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.
Type or Print Name: Kimberly Johnson
Title or Authority: Vice President
Signs Date:
I,...1,x.1tc1. e...1 iei Cliff/at ,a Notary Public of the County of...Cdt.W. ,
State of.e:.OI JJC ,do hereby certify that Kimberly Johnson ,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 tI day of ./.11arrin ,20.
Notary .t1'.il.Lh.€ik ik . r ,,,,,qn,GUI.
�,,,,,
Gi
Public Name: •`o' .S. �Q •.„,
Notary Public Signature: �'t...d..1.A p. = r�P i�•' 4 It
1. = i0
My commission expires: ..1.1' Q ..ZQ2 € Co g810Ns } t j i
eha it
.,,,.....1 C'OON,C1