NCC230914_MODIFICATION Supporting Doc (LOT 8)_20230503 (2)

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INOIVISION S
Excellence through Service
Single -Family Dwelling
Erosion Control P e r m i t Application
IlunlunG�im
City of Winston-Salem
Bryce A. Stuart Municipal Building
Suite 328
100 E. First Street
Winston-Salem, NC 27101
Field P.O. Box 2511
Operations Winston-Salem, NC 27102-2511
Please use this form when the Developer and Builder are not the same Phone: [phone]
p 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: g36& [Ae'm l-)roye.- CI- Le-W i S. L/ le. 70-23
Subdivision Name:
Anticipated Dates of Construction Activity: Start: 5- q- 20 21 Completion: 10 - 6 -
3
*** 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
Lt✓
Address: bt?y ect %Uo
City/State/Zip:(Jle-mmons A / 27011 Office Phone:
Mobile Phone: 33-?Nib- gk6g Email Address:Qrh�+c.lu llt kh.'fA-&eA ca.};enhoMts. Cow.
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 LIDO 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.
)uo 1�d -76 H
Print Name of Financially Responsible Person Signature of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:

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