NCC221791_FRO Submitted_20220510

Bryce A. Stuart Municipal Building
Ete 328
100
0
100E First Street
Single-Family Dwelling C;cvof Wsalem Winston Salem, NC 27101
INSPEC I IONS pp Box 2511
DIVISION Field NC 27102-2511
F+cr7l4nce (Aroagh Slnid Winston-Salem,
Erosion Control P e r m i t Application operations
Phone 311 or [phone]
Please use this form when the Developer and Builder are not the same 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:
Subdivision
M /"
Anticipated Dates of Construction Activity: Start: !F- —"
Z _Completion:
'*' 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: 011— r_ 1 N L � C
0,
Address:QUBD
City/StatelZip:L41-4-Wi-5b' L,L e 1-17-70Z3 Office Phone: 377
Mobile PhonEmail Address;, .�b� IMr��/a�Csi�s' GO'�
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.
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 andlor Civil Penalty Assessments for failure to comply with Erosion Control requirements.
i
Print Name of Financially Responsible Person Signature of Financially Responsible Person
TO BE COMPLETED BY CITY STAFF ONLY:
Date of Application Submittal:
Permit Number: