NCC217076_FRO Submitted_20220105

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INSPECT DNS
DIVISION
Excellence through Service
Single -Family Dwelling
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City of Winston-Salem
Erosion Control P e r m i t A nlication Field
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Bryce A. Stuart Municipal Building
Suite 328
100 E. First Street
Winston-Salem, NC 27101
P.O. Box 2511
Winston-Salem, NC 27102-2511
Please use this form when the Developer and Builder are not the same Phone: 311 or [phone]
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: 2,(.Q, 1 C I�,u, �,, 4�vo,. ?U.
Subdivision Name: 1. wWr� 61"
Anticipated Dates of Construction Activity: Start: _�1j T S ( Completion:5f
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*** 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. *1
Financially Responsible Party/Person
Address: ZZ3S� e.. ' �.-ewr3v� �� lGt�ty•zS ✓�(
City/State/Zip: C LIU#
f fIA 74,S ti'770D— Office Phone: 3 Co" 76 tp" 771S--
Mobile Phone:3 3G - 31 S = o 8 Email Address: o wt.+�" tQ ka"s b ySL ee.. co ti,
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.
So^n,V�c4^ M, L_-,,—
Print Name of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:
Sig ure of Financially Responsible Person
WS/FC EROSION CONTROL NOTICE
PLANS APPROVED FOR CONSTRUCTION
This plan complies with Chapter 8, Section 4 - Erosion Control
of the Winston-Salem/Forsyth County Unified Development
Ordinance. A printed set of the stamped/approved plans must
be kept on the construction site for reference when installing
required erosion control measures.
kentw
12/07/2021 9:46:27 AM