NCC222667_FRO Submitted_20220726

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Single -Family Dwelling
p- Bryce A. Stuart Municipal Building
'l1llJ' Suite 328
100 E. First Street
eno�wsaiem Winston-Salem, NC27101
1'r"flacerkm*S"m Field P.O. Box 2511
Erosion Control P e r m i t Application Operations Winston-Salem, NC 27102-2511
Please use this form when the er 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
Site
Subdivision Name: -C�, 11-j f7C t.)K-g\- r(-
Anticipated Dates of Construction Activity: Start; u)oe, 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. ***
Financ
Name
Addre
S5 i ffice Phonetate/Zip: 0:12I\1 r 97e222:
Mobile Phone: �-) 66J6 7Z— Email
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.
Print Name of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:
Signature of Financially Responsible Person