NCC221130_FRO Submitted_20220329

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Bryce A. Stuart Municipal Building
Suite 328
a
Single -Family ©welting
100 E. First Street
1 ISPECTIUM
cityofmmsaii
S
Winston-Salem, NC 27101
DIVISION
fXC611611a Iftraugh serp
ce Erosion Control P Q r m 1 # Application Field
PP
P.O. Box 2511
Operations
Winston-Salem, NC 27102-2511
Please use
this 'form when the Developer 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 Fie
eloped Information
Site Address:
L CiU 4
Subdivision Na
e:,
AnticipatedDa
s of Construction Activity: Start:_2Jt q J2'2 Completion: Z!t
..
2
' Complete th LOT INFORMATION TABLE for each lot to be developed; ensure that the appropriate drainage pattern type is
y
denoted. Attac a corresponding, existing platted survey for each lot with your application, please. It not, your permit
application manot be accepted for review. ***
Financially Responsible Party/Person
Name:
CitylState/Zip:
(NkC
Office Phone: 3
Mobile Phone: - 3 Email Address: ktAk4( ,VS&A . o C-^C&d oJV"A2A . 1011..
My signature heTE to signifies I am the ownerffinancially responsible party for job site compliance with the Erosion Control ordinance
as outlined in Chz pter, Section 8.4 of the Unified Development ordinances (UDO) of the City of Winston-Salem/Forsyth County or
Article IV of the U DO 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 tha if the total disturbed area for any reason becomes greater than one acre on any one (1) lot, a professionally designed
and seated Erosion Control Plan will be required to be submitted and approved before the start of the land disturbing activity on the lot. I
further acknowl ge 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 Fi ancially Responsible Person Signature of Financia ly Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:

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