NCC222074_FRO Submitted_20220606

s�"+'•o,, 111 Bryce A. Stuart Muddpel Building
If r Single -Family Dwelling (W soo E3Finit street
nvei ub� Wnston-Salem. NC 27101
r'dOn *P '�" W Erosion Control P e r rn I t Application Nerd g Box 2511
IMP OperaLlons v►kttuon-Salem. NC27102.2511
Please use this form when the Developer and Builder are not the same Far ( 3) 2 -279 747.7453
Fix- j336) 727-2782
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 WAY
Site Address: ��(/ _ 13QATt4 USF. AY —
Subdivision Name: (gotrp WA-'t_'0
Anticipated Dales of Construction Activity: Start: t 2Z _CompletIon. Q 11-
*** 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. B not, your permfl
application may not be accepted for review.''"''
Financially Responsible Party/Person
ve
Address: JID �AQ
CitylState0p:_ 4TOKj+ � r 7_73= r ice Phone:
Mobile Phone: 3;-qp- � (A- 33.E Email Address:_ �ZO 'O_ Ev_Q t0M5;6XNL- COM
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 Ordinanoes (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
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 anNor Civil Penalty Assessments for failure to comply with Erosion Contro4rs
�nntName of Financially aesponsible Person nature Financially Res nsi
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal;.
Permit Number: