NCC231853_FRO Submitted_20230615

_sunewr,, '(1 Bryce A.Stuart Municipal Building
till Suite 328
Single-Family Dwelling ,. 100 E.First Street
INSPEZ MIS
iNVI 1 N Field P.Q Box 2511
Frcefhruerhreupeservke Erosion Control Permit Application Operations Winston-Salem, NC 27102-2511
Please use this form when the andDeveloper
d Builder are not the same Phone:311 or(336)747-7453
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 11
Site Address: Xi .35 Cho.M'' w i' Foocyr 'Roo) (A;✓14,M - Slev►•, .2-7 1 DID
Subdivision Name: C-tn a- \Aavvx Fo-x—vV' � .0,�7
/
Anticipated Dates of Construction Activity: Start: ,*ta 3 Completion: may
***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 PartylPerson Name: A Ion G FleA-c-V‘e r COY Coy-v4vu
I' vY\ Co. ,Ii
Address: S S D Coy rc-r) 'Spa-GO
City/State/Zip: L.ew',bv Office Phone: 3 31, - 9 -
Mobile Phone: 4/6 5360- Email Address: Gtlo-vac e.4 erotdroDaz - COvvx
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.
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 co ply with Erosion Control requirements.
Skidl t5-✓‘ %
Print Name of Financially Responsible Person Signature of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: