NCC230095_FRO Submitted_20230112

p oWtip , V Bryce A. Stuart Municipal Building
Suite 328
�' Single -Family Dwelling lllmrni 100 E. First Street
city of Winston-Salem Winston-Salem, NC 27101
t�GIVIS10N s
fx uvncerhm osemee Application Field P.O. Box 2511
Erosion Control Permit A
Pp Operations Winston-Salem, NC 27102-2511
Please use this form when the Developer and Builder are not the same Phone: 311 or [phone]
financially responsible party/person and will be less than one (1) acre of Fax: [phone]
land disturbance on any one (1) lot.
Lot(s) to be Developed Information
Site Address. 613 b 1 FV ; pj�.
Subdivision Name: 13 - C. r' V V fes PI+ x
Anticipated Dates of Construction Activity: Start: N 0?3 Completion:
*** 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 PartylPerson
Name:_'(-LAYT-G I.t imc-p = (ZC 2a�,P NL
Address:_
City/State/Zip:_ W rru s 1'6N _ S,al 0 r e 11094 _office Phone: 3 J e - ;? 31" G9b 2 _
Mobile Phone: 3 T4-177- do 5 y Email Address: W W5M SG G) MuWp.�dM
My signature hereto signifies I am the ownerifinancially 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-Saiem/Forsyth County or
Article IV of the UDO of the Village of Ciemmons, 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 StafI may refuse to make building inspections arid the Erosion Control Division may issue
Notices of Violation, Stop Work Orders andlor Civil Penalty Assessments for failure to comply with Erosion Control requirements.
L L DE R i C.tILSCs
Print Name of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:
Sign re of Financially Responsible Person

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PLEASE COMPLETE ALL ENFp RMATION FOR EACH LOT
TO BE 15EVELOPEC. ENTER THE ORAINAG6 PATTERN TYPE A B. C. D.E. F G OR H AS WELT. AS'RD' FOR ROAD WCH OR'CG' FOR CURB AND GUTTER M THE APPROPRIATE FIELD.
PARCEL NUMBER
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LOT NUFASER
DISTURBED AREA (ACRE)
70TAL LOT SIZE (ACRE)
DRAINAGE PATTERN TYPE
SPECIAL NOTES
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