NCC230914_MODIFICATION Supporting Doc (LOT 19)_20230816 (2)

PEEN:FORS,Y tl Bryce A.Stuart Municipal Building
of `yam Suite 328
z i `: Single-Family Dwelling „I,A,,„,t'"I 100 E.First Street
t C,tyofwinston-Salem Winston-Salem,NC 27101
INSPECT ONS
DIVISION Field P.O. Box 2511
Erosion Control P e r m i t Application OperationsWinston-Salem, NC 27102-2511
Please use this form when the Develo er and Builder are not the same Phone:3 747-7453
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:J'M 52g6r{otnl kawy\ CI. Le_wl:5Vlllt, ML L d
Subdivision Name SRC, L Ck Kit- 04 L i Ssc-Ir
Anticipated Dates of Construction Activity: Start: p/ N / '�0l3 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 Party/Person ,1
Name: i CA l��,�e t'a-��on Np me-s LL�.
Address:262S IJP(AA.c� R '_�T - _70o
City/State/Zip:c 4--mm OAS 1 OU R-)ola Office Phone: ��� - �0`1 -0��6
Mobile Phone: J3�a- Email Address: CkYV�l-kVel l 6CA ro l 'ae\61% God
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.
ALk H i J0, �twA4 T6 k
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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