NCC241755_FRO Submitted_20240610

sncnsYr '(1 Bryce A.Stuart Municipal Building
'� tip Suite 328
Single-Family Dwelling 100 E. First Street
! i Gty of Winston-Salem Winston-Salem,NC 27101
INSPE ONS
DIVISION Field P.O. Box 2511
Excellence fdmn°sari." Erosion Control Permit Application Operations Winston-Salem, NC 27102-2511
Please use this form when the Develo er and Builder are not the same Phone:[phone]
p Fax:[phone]
financially responsible party/person and will be less than one (1) acre of
land disturbance on any one (1) lot.
Lots)to be Developed Information Site Address: 37Z 6List4tek ,omart- Diz.zvz
Subdivision Name: kotti4E. k cj4 c -
Anticipated Dates of Construction Activity: Start: al/s/2 ' Completion: ih.hS"-
***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 /2.2-/ c,E Gana 7-itvc7 by
Address: /?c • /3Q)( a2z20
City/State/Zip: 4p wet- /LL Sao C Office Phone: 73G 9 /
Mobile Phone: 3�6 3Vc /o'/ Email Address: ,(,€,Cag._/ZA.a.X-r�ix& 01.Sfl i 7Z w, cowl
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.
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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: