NCC233373_FRO Submitted_20231113

Sp�F"`lFO"Sr� (1 Bryce A.Stuart Municipal Building
�o� yCC Suite 328
Single-Family Dwelling IllmlonSvrm 100 E.First Street
City of Winston-Salem Winston-Salem,NC 27101
INSPECT DNS'
DIVISION Field P.O. Box 2511
Excellence through Service Erosion Control Per m i t Application PP Operations Winston-Salem, NC 27102-2511
Please use this form when the Developer and Builder are not the same Phone:311 or(336)747-7453
Fax:[phone]
financially responsible party/person and will be less than one (1) acre of
land disturbance on any one (1) lot.
Lot(s)to be Developed Information /
Site Address: 7 I L 1 NIJE 1J 4R 1) W41 l U)I STO&J 34LEJJ N G 21106
Subdivision Name: QM.C /4T C HA THA/h
Anticipated Dates of Construction Activity: Start: /d//15/?pZ S Completion: 6/6/20Z y
***Complete the LOT INFORMATION TABLE for each lot to be developed; ensure that the appropriate drainage pattern type is
denoted. Attach a corresponding,existing platted survey for each lot with your application, please. If not,your permit
application may not be accepted for review.***
Financially Responsible Party/Person
Name: 1\rd elf. Ci r o tkp, L.L..
Address: To 130( 5.323
City/State/Zip: W i J SHIN SittE 01 IX 2. /f/, Office Phone: �7v 6611.4? 75O
Mobile Phone: 336•h 7 t (o 10 I Email Address: CO n S4 r U C+lO Agin wt%h • abort/
My signature hereto signifies I am the owner/financially responsible party for job site compliance with the Erosion Control Ordinance
as outlined in Chapter,Section 8.4 of the Unified Development Ordinances (UDO)of the City of Winston-Salem/Forsyth County or
Article IV of the UDO of the Village of Clemmons,Town of Lewisville,or Town of Walkertown. I hereby acknowledge that the Best
Management Practices annotated on the attached sketch plan must be properly installed and maintained to retain soil within the
constructed lot.
I understand that if the total disturbed area for any reason becomes greater than one acre on any one(1)lot, a professionally designed
and sealed Erosion Control Plan will be required to be submitted and approved before the start of the land disturbing activity on the lot. I
further acknowledge that City Inspection's staff may refuse to make building inspections and the Erosion Control Division may issue
Notices of Violation, Stop Work Orders and/or Civil Penalty Assessments for failure to comply with Erosion Control requirements.
S' rv, QT Ti4Q ICS
Print Name of Financially Responsible Person Signatur of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:

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