NCC241700_FRO Submitted_20240607

4,03.04 FPS`' (1 Bryce A.Stuart Municipal Building
hQ ¢ Suite 328
Single-Family Dwelling tt:sre,;. ,„ 100 E.First Street
IN$PEC ORS City of Winston-Salem Winston-Salem,NC 27101
DIVISION
Excellence throughsemi" Erosion Control Permit Application Field P.O. Box2511
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
Site Address: (L( - `hl , 7 R, �/
Subdivision Name: / �1..L L�t , ScL
Anticipated Dates of Construction Activity: Start: S~- d 4 Completion: - 2- _ z.s
***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: rA Y\ t-1--L. (7.4zv s- H 1
Address: / 2 kf 4 1. /
City/State/Zip: J) - 5 4 ' - `7 J 0 Office Phone:
Mobile Phone: "3 _44 2--ti y 6 2 Email Address: 114 n ri, 7z-,2,' & /14 ,'/.
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.
I�,,�/i/^ � _,/ �� � JEANETTE WEAVIL �'
z" T/ Notary Public
Print Name of Financially Responsible Person Forsyth Co.,North Caro' a ,
My Commission Expires Fob.110,'Mine of Financially Responsib er on
Stt N('
County of:
TO BE COMPLETED BY CITY STAFF ONLY: The foregoing instrumen was acknowledged
b ore a lit) day of t
Date of Application Submittal:
Permit Number: blame Here, Notary Public
/ My Commission Expires Ali ( 9-7).