NCC241468_FRO Submitted_20240515

N�"n`t+, _ 11pJ Rryr.r A Stuart Muniap.a Ri fmg
Suite 320
' 4` t f)r)F Fist St!net
\ Single-Family Dwelling " wt on-&,k„t. NC27ttn
1115P
OnnSOe Field RO Sox Z511
`'"*""" '"s""' Erosion Control Permit Application operations Wrisst,tt Salem. Nc»t^22511
Please use this form when the Developer and Builder are not the same i` 31` n'' `t 7a7 7453
P na,t.c336:721-2/9a
financially responsible partyiperrson and will be less than one (1) acre of
land disturbance on any one (1) lot.
Lot(s)to be Developed Information
Site rcidress 1702 91J J O j.t'.1» inj C-+
Subdivision blame-_ 13*fDV-b C 3 �[�r rtl1
Anfcaci i d Dates ue:of Constr iun Acrivit Sta? I _47 completion: [- 1 1 1?- _
*"Complete the LOT INFORMATION TABLE for each lot to be developed;ensure that the appropriate drainage pattern type is
denoted. Attach a corresponcfir g.existing platted survey for each lot with your application,please. If not,your permit
application may not be accepted for review."'
Financially Responsible Party/Person
Name., Pr H etc re: a C ' en � n C •
Address: 1 � 9 ' 'Y1 1 !Gi -
CitytState/Zlp: L W i•SV y 1 . NI C.. 2-'3-e 2.3 Ctce Pt'iris: 3 3 6 - 71��2- o 1
Mobile Pttione:J 3 L- 2.—0 3S Email Address-. rt i 47 ei ;crf-yr et; )
My signature hereto signifies I am the owner?hnancaay responsible party for ob site compliance with the Erosion Control Ordinance
as outlined in Cizapter,Sec non 8.4 of the Ulu ied Developnxnt Ordinances(UDC)of die City of Winstrn-SalemFcrsyth County or
Artrle IV of the I1CO of the V lane of Clemrnons,Town of t ewisviile,or Town of Walkertown.I hereby acknowledge that tip Best
Management Pra lines annotated on the atttactied ske} plan must be properly instailal and maintained to retain soil within the
constricted lot.
I tmderstam that if he total disturbed area for any reason bee nrttes greater than one acre on any one(1)lot a pro s`sionally designed
and seed Erosion Control T'gar.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 made building inspections and the Erosion Control Division may issue
Notices of'.rotation. Stop Work Orders andt'oe Civil Penalty Assessments for Iaik;'e to comply with Erosion Control requirements.
Pnni fJ l e i Fi�ialty Responsibtc Person SignaturE Fs cially Responskie Person
TO BE COMPt STED BY CITY STAFF ONLY:
Date of Apl icat'r,Submittal=
Permit Number.