NCC241937_FRO Submitted_20240625

Sa�tta;FOKsr p Bryce A.Stuart Municipal Building
or' Suite 328
- Single-Family Dwelling �1n,1�4vra
100 E.First Street
City of+.v r.:a s:,• aiem Winston-Salem,NC 27101
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DIVISION Field P.D. Box 2511
1"efi `P'nroU7hs'rvi" Erosion Control Permit Application Wins on-Salem, NC 27 1 02-251 1
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Please use this form when the Developer and Builder are not the same Fax:( 311 or(336)747"'ass
P Pax:[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: 8` Z LT&SE C'T. L EL) 3 V I LL 1.1 C . Z Z 3
Subdivision Name: (A)COO) VIA W E-5-FlicrreS
Anticipated Dates of Construction Activity: Start: co/i J / �t Completion: 9 Z//-7 / 2 y
'Complete 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: P7,09 t/ Oiic oc72 s 2TA/ .
Address: ✓i'' AA/b .
City/State/Zip: A'Z-RN 5"-///e.` A/e_ Z 7 z 9ca Office Phone: 3 c- 7`1 Z
Mobile Phone: Email Address: ir7 ®Al a,'e 6 i i/d r s.c0,71
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 ignature of Financially Respo le Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: