NCC233574_FRO Submitted_20231204

sw�Em/►aysyr (1 Bryce A.Stuart Municipal Building
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Single-Family Dwelling &sum.L'ium 100 E.First Street
INSPECT DNS City of Winston-Salem Winston-Salem, NC 27101
DIVISION
Excellence thronghService Erosion Control Permit A lication Field P.O. Box 2511
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
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 /1 ��
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Site Address: �`� JJ® �""-1 �-- � � Ltk-iu_ UV cj Oc a') I (X/:
Subdivision Name: (. 9 y 7 9)00 (V r e J �e''G7i--i / 9 Pa a___,a— I
Anticipated Dates of Construction Activity: Start: /7-TO -0,21 ,g Completion: ( `WOo?/
***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: (()_y___ --_- __- - _ _ L/.5� /1/7-7,4 J� /7.t' t �
Address:
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City/State/Zip: ltJCi7Sir'} digile.ya/
.4/( r -7l/ Office Phone: .3�i S��- r��44
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Mobile Phone:!-3�i� •_3 Lea . d95 Email Address:.004 e home jharn ru/. (G27'L-�/
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/vOrlh rosion Control requirements.
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Print Name of Financially Responsible Person Signature of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: