NCC241753_FRO Submitted_20240610

Bryce A.Stuart Municipal Building
t!!J Suite 328
Single-Family Dwelling of 100 E.First Street
City of WknstWinston-Salem,NC 27101
INSPE ONS
DIVISION Field P.O. Box 2511
it'd/en"(bmugb5avi" Erosion Control Permit Application Operations Wnston-Satem, NC 27102-2511
Please use this form when the Develo er and Builder are not the same Phone:311 )747-7453
p 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
Site Address: 9 tee) SS,4Rf CAS,f' C-r
Subdivision Name: .'.s4-A E
Anticipated Dates of Construction Activity: Start: a&-/$V Completion: C/s AS-
***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 Party/Person
Name: ,/Q A ca'v67'7cC# 7 't/, ror1.
Address: I . /.3ox 2Z2.a
City/State/Zip: /1/J'RIL-GC NG 2700 6 Office Phone: 336 70/ Cs
Mobile Phone: 33L Sys A2V/ Email Address: / /Q co I icue7=ctrti- co.+1
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 Signature of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: