NCC220731_FRO Submitted_20220211

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INSPECTIONS'
DIVISION
Excellence through Service
Single -Family Dwelling
Erosion Control P e r m i t Application
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City of W inston-Salem
Bryce A. Stuart Municipal Building
Suite 328
100 E. First Street
Winston-Salem, NC 27101
Field P.Q Box 2511
Operations Winston-Salem, NC 27102-2511
Please use this form when the er and
Builder are not the same Phone: 311 or [phone] financially responsible party/person and will be less than one (1) acre of Fax: [phone]
land disturbance on any one (1) lot.
Lot(s) to be Developed Information
Site Address: 9407, 9431, 9437, & 9406 White Tail Trail, Kernersville, NC 27284
Subdivision Name: Deer Path phase 3
Anticipated Dates of Construction Activity: Start: 2/01 /2022
Completion: 12/30/2022
*** 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: W. R. Hutchings Construction, LLC
Address: P.O. Box 1716
City/State/Zip: Kernersville, NC 27285 Office Phone:
Mobile Phone: [phone] Email Address: [e-mail]
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 LIDO 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.
Walter R. Hutchings, III
Print Name of Financially Responsible Person Signature of Financially Responsible Perso
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: