NCC241688_FRO Submitted_20240604

Suite
►* UV First Street
City
Munuupal Bullring
Single-Family Dwelling City o� ;�00„ s,l 14C viol
istifril
`""mmt"."""" Erosion Control Per m i t Application Reid s«ns ie rc27102-2511
Please use this form when the Develo r and Builder are not the same Fax:(.311 or(336)747 7453
� Fax:r33s)727-2792
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 Informationio 7/ (- rti() /Site Address: ` GL ,� I / o_ 7/(sy-
Subdivision �Name: 6 Lc l c;�-tvo /25fCF fit.44.5/0 ` r
Anticipated Dates of Construction Activity Start: Le— 3 — ) Completion: / 2_—31_--��L
""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 surrey for each lot with your application,please. if not,your permit
application may not be accepted for review.
Financially Responsible PartylP n �+I� _
Name: Lit (<94C/' /( /7 $ „ji'V
Address: /72 0,Xe 7 L w/,3 Ul`j 27 n2 3,
City/State/lp: t---C 14/11 U I4 11,V L "2 7 0fface Phone:
k4obile Phone' Email Address: tJ 97J' o,,)f< © ,.a`
My signature hereto signifies I am the ownerlfinancially responsible party for job site compliance with the Erosion Control Orline
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 anyone(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 a building inspections and the Erosion Control Division may issue
Notices of Violation, Stop Work Orders and/or Civil Penalty ssments for failure to comply with Erosion Control me
Cilz.:
- //te t '4/H
Print ame of Fl laity Respo Pe i S of Financ Re Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number.