NCC232512_FRO Submitted_20230821

ptEMFRISyT � Bryce A.Stuart Municipal Building
oay till Suite 328
;yti �= Single-Family Dwelling fWinston 100 E.First Street
City of Winston-Salem Winston-Salem,NC 27101
INSPECT ONS
DIVISION Field P.O. Box 2511
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ence dff"gh SetVfee Erosion Control Permit Application OperationsWinston-Salem, NC 27102-2511
Please use this form when the Developer and Builder are not the same Phone:311 or 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: / Sos tt"vl�LJM%'0% ° teC4A-ri. SOK-
Subdivision Name: AVIAv&J C' (_A G
Anticipated Dates of Construction Activity: Start: 42.1[2,3 Completion: 1I51 l?-
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 Res a onsible Party/Person
t
Name: ('—lA llop saI)A..) CA)SIN PA— fEC G Address: (?j(,,„g 114
City/State/Zip: ��lAJ Office Phone: 3�'-uC Co
Mobile Phone:' L 3 11-Z164 Email Address: lit.. ysE�E. ukrc-Q7 �1•c.' "'
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.
Print Name of Financially Responsible Person Signature ofFinancia y Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: