NCC240350_FRO Submitted_20240209

P Bryce A.Stuart Municipal Building
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Erosion Control P exnmit Application �pa�Uoms mxo�o~��~ wnznn2-zo11
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Please use this form vvhenthe Developer and Builder are not the 88rn8 p �m� / vnu�'
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financially responsible part 'pengonmndm/iUbe |assthamVne (1) 8cne0f
land disturbance n0 any one 1) |V1.
Lu%s)bab*Developed Information
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Site Address: � m/0
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���m Name-, / "'e /� '�� ?/_ �«�� m��� / *'#0
Anticipated Dates of Construction Activity: Start: } - �' 2-119 —Completion,-
**' Complete the LOT INFORMATION TABLE for each| typo is
denoted. Attach a corresponding,existingplatted survey for each lot with your application, please. If not,your permit
application may not bw accepted for review.
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Financially Responsible Party/Person
Name 1 4et1*' /-ew 5-�*u f.
Address.- F0. 60y � 7 Y --- -
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CityiState,ZP /- yew ~n,�W5 70/2- Office Phone:
Mobile Phone: D4~P13'a717 EmaUAddres»i
My signature hereto signifies I am the ownerifinancially 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 the8ea\
Management Practices annotated on the attached sketch plan must be properly installed and maintained to retain soil within the
constructed lot,
| understand that if the total disturbed area for any reason becomes greater than one acre on any one(1)lot,a professionally designed
and seated Erosion Control Plan will be required to be submitted and approved uefore the start of the land disturbing activity on the loL 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 FmonuaUyRemponuib}ePerson S ��Finando||yRespoos/b/ePamon
TOBE COMPLETED 8Y CITY STAFF ONLY:
Date u[Application Submittal:
Permit Number. _
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