NCC241677_FRO Submitted_20240604

��tMiroR:, (1 Bryce A.Stuart Municipal Building
�o+o (It Suite 328
Single-Family Dwelling „ 100 E.First Street
i City of Winston-Salem Winston-Salem,NC 27101
INSPEC ONS
DIVISION Field P.O. Box 2511
r"""""hrough Senna' Erosion Control Permit Application Operations Winston-Salem, NC 27102-2511
Please use this form when the andDeveloper
d Builder are not the same Phone:311 or(336)747-7453
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: 9.537 Lissara Camp Court
Subdivision Name: 1-y SSAkA L.r4Ke
Anticipated Dates of Construction Activity: Start: 24- Completion: 7"‘ ' z
***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: j grRtt>0L DES 16A'3. LL e (EtivY sco fires
Address:PO 714) l''gf.5 lAAr 17/1
City/State/Zip: 1-:6- JiSi/,LLL` Al , 21043 Office Phone: 33e-8/5-1J7.7
Mobile Phone: -8/3 '/377 Email Address/Qt1PP// 7 MS1? WoJDe.Si fNS C041
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 of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: