NCC221035_FRO Submitted_20220317

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INSPECTIONS,
DIVISION
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Single -Family Dwelling
Erosion Control P e r m i t Application
City of Winston-Salem
Bryce A. Stuart Municipal Building
Suite 328
100 F. First Street
Winston-Salem, NC 27101
Field P.Q. Box 2511
operations Winston-Salem, NC 27102-2511
er and Builder are not the same Phone: [phone]
Please use this form when the Developer 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:
Subdivision Name: woa
Anticipated Dates of Construction Activity: Start: aIG (M _Completion:
*** 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:
Address:
C41State/Zip: �p�,a a s ;l C IVY z7 o L3 Office Phone:
Mobile Phone: 44 -7 f Vs. Email Address: k • s ,s�sr - <�? 9, v,.,, l .moo -,,•-
My signature hereto signifies I am the ownerlfinancially 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-SalemlForsyth 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
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:7,1'7 (7'L
Permit Number:
Signature of Financially esponsible Person