NCC222165_FRO Submitted_20220617

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FxcelkXe lbmagb Servra
Single -Family Dwelling
p, Bryce A. Stuart Municipal Building
Suite 328
100 E. First Street
cRryofw Rsto�LL-m Winston-Salem, NC 27101
Field P.Q Box 2511
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.
Lot(s) to be Developed Information
Site Address: fie%C7 (a Cel C-
Subdivision Name: CbLOw�'[�fL rr
Anticipated Dates of Construction Activity: Start: 2 1 II �, 22 Completion: V* 1 5 2Z
*** 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. I
Financially Responsible Party/Person
Name:_MID L-L C
Address: a (oOq SGO f�fo ++ S �-o " "•.•���i.iC_ t _
City/State/Zip: , A W_ R s nt.F_ _ W C 1131 O Office Phone: " 5100 r 60 7" i
Mobile Phone:12�11 %b1— Ica-li'll Email Address: V&Ea4 AC 1%jv r r,—oF5-4.S Vl-%t> . COw1
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 U0f0 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:
Permit Number:
Signature o Financially Res ible Person