NCC221170_FRO Submitted_20220330

'00/l4
N��'PECilO11S
VISION
Single -Family Dwelling
(1, Bryce A. Stuart Municipal Building
I1�1J1 Suite 328
100 E. First Street
Gtvof Winston-Salem Winston-Salem, NC 27101
tufflem,,, v* SWV;n Field P.O. Box 2511
Erosion Control P e r m i t Application 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 Developed Information
Site Address: L,'' _Q any, c'�--,
Subdivision Name: I N
Anticipated Dates of Construction Activity: Start: ; — Completion: _,MDV.
*** 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. ***
City/State/Zip: LG!-�J% s i I -p- a22 �4 zo 1 —3 Office Phone:
Mobile Phone: `Irl�-bv(��L Email Address:
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
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number:
4n_7z6"-
Signature of Financially Responsible Person